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.
If additional media or files need to be included with the report, please list them and attach them to the report e-mail once you have signed
the report and clicked the submit button)
Worker Recommendations (Please provide recommendations that might contribute to preventing future occurrences)
Signature
Review report prior to signing.
Once signed, all above fields will lock
and SUBMIT button will appear.
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
Submitted By
Submitter Email
INCIDENT/NEAR MISS REPORT
click to sign
signature
click to edit