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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
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INCIDENT/NEAR MISS REPORT
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