Report A Near Miss/Incident/First Aid
Report A Near Miss/Incident/First Aid
Please Complete All Fields
Type of Report
*
Near Miss
Incident
First Aid for Student
First Aid for Employee
First Aid Other
Date of Incident
Date of Incident
/
MM
/
DD
YYYY
Time of Incident
Time of Incident
*
:
HH
MM
AM
PM
AM/PM
Name of Person Reporting
Name of Person Reporting
*
First
Last
Department/Program
*
Location
*
Castlegar Campus
Silver King Campus
Tenth Street Campus
Trail Campus
Grand Fork Campus
Other - Please include in Description
Name of Individual Receiving First Aid
Name of Individual Receiving First Aid
First
Last
Who is the Injured Person
Who is the Injured Person
Student of Selkirk College
Employee of Selkirk College
Community Memeber
Other
Form 6a was given to employee
*
Form 6a was given to employee
Yes
No
Did the Injured Person
*
Did the Injured Person
Return to Work (Class)
Medical Aid
Ambulance
Brief Description of Injury - eg Laceration to right arm or unconscious
Must be between
1
and
20
words.
Currently Entered:
0
words.
Detailed Description of What Happened.
*
Were there any other witnesses or other people involved?
*
Were there any other witnesses or other people involved?
Yes
No
If "Yes", list names and contact information
Option to Upload a Photo
Please Confirm you have informed your immediate supervisor
*
Please Confirm you have informed your immediate supervisor
Yes
Will be done immediately
UCIPP form has been filled out and sent to healthandsafety@selkirk.ca
*
UCIPP form has been filled out and sent to healthandsafety@selkirk.ca
Yes
No
Other
Has the Employer Incident Investigation Report (EIIR) been started
*
Has the Employer Incident Investigation Report (EIIR) been started
Yes
No
Other
Please enter your email for follow up from Health & Safety
*
Submit