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Incident Accident Report Form Template

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Incident Accident Report Form Template Powered By Docstoc
					College of _________ Incident Report Form
This form is to be used to report both „non-critical‟ and „critical‟ incidents which occur at the main/regional campuses or involve employees and students taking part in a COLLEGE NAME related activity. A „non-critical‟ incident is an incident outside the normal range of daily experiences. While such incidents might be considered minor, the impact is sufficient to cause concern For illustration purposes, some examples of non-critical incidents would include, but not be limited to:          minor property damage suspected fire danger minor physical injury emotionally distraught person hostile exchange between individuals “bullying”, verbal abuse unusual presence of person or persons causing concern (loitering, possible „stalking‟ of self or others) suspected physical abuse suspected suicidal intentions A „critical‟ incident is a traumatic event which is outside the ordinary range of human experiences. Such events are usually sudden and powerful. These occurrences have a strong emotional impact sufficient to overwhelm the usually effective coping skills of either an individual or group. For illustration purposes, some examples of critical incidents would include, but not be limited to:      serious injury or sudden death of a colleague or student incident with significant media attention hostage taking bomb threats major destruction of the work/learning environment due to a natural disaster

Please type or print in block letters. Continue on back if more space is required. Location of campus: { } Cranbrook { } Creston { } Invermere Date of Incident { } Elkford { } Kimberley { } Fernie { } Golden { } Sparwood Time of Incident:

Incident Reported By: Description of Incident and/or Injury:

WITNESSES - If more than 2 witnesses, continue on back. 1. Name of Witness

Location: { { { { { { { { { { { { { { { } } } } } } } } } } } } } } } Classroom { } Cafeteria/Lunchroom Mt. Fisher Bldg. { } Shops/Labs/Kitchens Hallway/Lockers { } Residence Playing Fields { } Industrial Park Gymnasium/Auditorium Library/Office/Lounge/Study Room Washroom/Changing Rooms/ Showers Playground Equipment Sidewalks/Roads Off Facility Property Stairs Within Building Stairs/Sidewalks Within Grounds Students Union Office Doors/Entrance Areas Industrial Park Parking Lot { } Other:

Activity of witness at time of incident.

2.

Name of Witness

Activity of witness at time of incident:



There were no witnesses to the incident.

Action taken/contacts made by you, if any.

Name of Person Involved in Incident Home Address Student/Staff/Other - please explain Was First Aid treatment required? Full Name of Person Completing Report - please print Title Yes City

Age - For statistical purposes only  Male

Gender - For statistical purposes only  Female Postal Code Business:

Phone Number: Home: No Ph# Signature

Date:

Other Information/Comments: if more space is required, continue on back PLEASE RETURN COMPLETED FORM TO THE HUMAN RESOURCES DEPARTMENT OR THE MANAGER OF FACILITIES

Property Involved – Describe property involved.

Cause of Loss/Damage:

 Falling Object  Glass Breakage  Vandalism  Windstorm/Hail
Additional Space

 Smoke  Theft  Water/Escape/Rupture/Freezing  Other – please explain

FOR FACILITIES AND/OR THE HUMAN RESOURCES DEVELOPMENT DEPARTMENT USE ONLY: Please type or print neatly


				
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