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Health & Safety Occurrence Report

In an emergency call 911. Serious injuries and all occurrences involving persons on campus must be reported immediately to Safety & Security! Call 902-585-1103

IT IS THE SUPERVISOR’S RESPONSIBILITY TO COMPLETE THIS REPORT WHEN THERE HAS BEEN AN OCCURRENCE INVOLVING FACULTY, STAFF OR STUDENTS. Reports should be completed within 2 business days. IF YOU REQUIRE ASSISTANCE, PLEASE CALL 902-585-1576

NOTE: All fields are required on this form.

Details of person involved
(This question is mandatory)
Details of person involved in incident
(This question is mandatory)
Status of person involved in incident
Details of occurrence
(This question is mandatory)
What assistance did the person need (if any)?
(This question is mandatory)
Activity location
(This question is mandatory)
Near miss?
(This question is mandatory)
Damage to University property?
(This question is mandatory)
Date and time of occurrence
Open date/time selector
(This question is mandatory)
Date and time occurence reported
Open date/time selector
(This question is mandatory)
Location of occurrence
(This question is mandatory)
Description of occurrence (please describe EXACTLY what happened)
(This question is mandatory)
Nature of injury/damage, if any (e.g. cut left index finger)
(This question is mandatory)
Describe unsafe acts and conditions that directly contributed to the occurrence
(This question is mandatory)
Describe underlying or root causes. Ask WHY unsafe acts/conditions existed. Continue to ask WHY questions until root causes are identified
(This question is mandatory)
Describe corrective actions completed, planned, and/or recommended. Be specific. Include action persons and target dates for completion
(This question is mandatory)
Were others involved in the occurrence?
(This question is mandatory)
Please descibe any involvement by other people in the occurrence
Details of person reporting
(This question is mandatory)
Details of person reporting occurrence
 
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