Date of Incident Campus Location/Building
Did the incident result in Injury Property Damage Near Miss Uncertain
Persons Involved (list additional individuals in Incident Narrative if necessary)
Regular Temp Contractor Student
Regular Temp Contractor Student
Regular Temp Contractor Student
Regular Temp Contractor Student
Incident Narrative
(Provide as much information as can be recalled. Do not theorize or offer opinions, just include the facts. List the names of any witnesses.
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Worker Recommendations (Please provide recommendations that might contribute to preventing future occurrences)
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Joint Occupational Health
and Safety Committee
11401 - 8th Street
Dawson Creek, B.C.
V1G 4G2
Ph: 250-782-5251
Fax: 250-782-5233
562/14.04.11-j
Submission Page 1 of 2
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INCIDENT/NEAR MISS REPORT
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Review Date Second Review Date
Witness and Investigation Narrative
Provide the findings from witness questioning and evidence review. DO NOT include personal opinions or views
Physical Findings Note any measurements, samples taken or any additional files (digital pictures) that may be attached to this report.
Additional Comments
Conclusions
All conclusions on contributing factors should be listed here. Include all possible causal factors. Do not list prevention points in this field.
Recommendations Provide recommendations to the employee or the College on preventing future occurrences
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JOHSC Management JOHSC Union Representative
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Joint Occupational Health
and Safety Committee
11401 - 8th Street
Dawson Creek, B.C.
V1G 4G2
Ph: 250-782-5251
Fax: 250-782-5233
562/14.04.11-j
Review Page 2 of 2
Investigation Team
INCIDENT/NEAR MISS REPORT
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