ࡱ> wztuv? bjbj v<hhhh&0&0&0&0&0&$T&T&T&P&l(LT&}\*H 4L4448678t{{{{{{{$kX{0&9868699{0&0&44H|6C6C6C9j0&40&4{6C9{6C6Cctg4p@r69B\e4{|0}eÂ:Âhtg,gJÂ0&g996C99999{{B999}9999Â999999999X $: Employer Incident Investigation Report (EIIR)Please refer to the companion  HYPERLINK "http://www.worksafebc.com/forms/assets/PDF/52E40Guide.pdf" quick guide for assistance completing the investigation and this form. 1. Employers information Employers name (legal name and trade name)  FORMTEXT School District 79, Cowichan ValleyWorkSafeBC account number  FORMTEXT 579607Operating location number  FORMTEXT n/aEmployers head office address  FORMTEXT 2557 Beverly StreetCity  FORMTEXT DuncanProvince  FORMTEXT BCPostal code  FORMTEXT V9L 2X3Employers representatives name  FORMTEXT Mary Jo WilsonPhone number (include area code)  FORMTEXT 250-252-0629Email address  FORMTEXT healthsafety @sd79.bc.ca2. Injured persons Last nameFirst nameJob titlea)  FORMTEXT       FORMTEXT       FORMTEXT      b)  FORMTEXT       FORMTEXT       FORMTEXT      c)  FORMTEXT       FORMTEXT       FORMTEXT      d)  FORMTEXT       FORMTEXT       FORMTEXT      3. Place, date, and time of incident Location where incident occurred (street address or GPS coordinates)  FORMTEXT      City (nearest)  FORMTEXT      Province  FORMTEXT      Postal code  FORMTEXT      Date of incident (yyyy-mm-dd)  FORMTEXT      Time of incident  FORMTEXT       FORMCHECKBOX  a.m.  FORMCHECKBOX  p.m.4. Type of occurrence (select all that apply)  FORMCHECKBOX  Death of a worker  FORMCHECKBOX  Serious injury to a worker  FORMCHECKBOX  Major structural failure or collapse  FORMCHECKBOX  Major release of hazardous substance  FORMCHECKBOX  Blasting accident causing personal injury FORMCHECKBOX  Dangerous incident involving explosives other than blasting incident  FORMCHECKBOX  Diving incident, as defined by regulation  FORMCHECKBOX  Incident of fire or explosion with potential for serious injury  FORMCHECKBOX  Minor injury or no injury but had potential for causing serious injury  FORMCHECKBOX  Injury requiring medical treatment beyond first aidAn incident investigation report is NOT required under the Workers Compensation Act if none of the above applies or if this incident is a vehicle accident occurring on a public street or highway.5. Report type (select all that apply) If this is a revised version of a previous report, please check here  FORMCHECKBOX   FORMCHECKBOX  Preliminary Investigation Report FORMCHECKBOX  Interim Corrective Action Report FORMCHECKBOX  Full Investigation Report FORMCHECKBOX  Full Corrective Action ReportReport date (yyyy-mm-dd)  FORMTEXT      Report date (yyyy-mm-dd)  FORMTEXT      Report date (yyyy-mm-dd)  FORMTEXT      Report date (yyyy-mm-dd)  FORMTEXT      Only provide to a WorkSafeBC officer if requestedMust be provided to WorkSafeBC within 30 days* Fax 1.866.240.1434Officer s name  FORMTEXT      Date sent (yyyy-mm-dd)  FORMTEXT      6. Witnesses Last nameFirst nameJob titlea)  FORMTEXT       FORMTEXT       FORMTEXT      b)  FORMTEXT       FORMTEXT       FORMTEXT      c)  FORMTEXT       FORMTEXT       FORMTEXT      7. Other persons whose presence might be necessary for proper investigation Last nameFirst nameJob titlea)  FORMTEXT       FORMTEXT       FORMTEXT      b)  FORMTEXT       FORMTEXT       FORMTEXT      8. Sequence of events that preceded the incident Required in Preliminary Report. Update in Full Report if necessary. Describe events earlier that day or even in previous years that led up to the incident. Examples may include events such as training given or changes in equipment, procedures, or company management.  FORMTEXT       9. Unsafe conditions, acts, or procedures that significantly contributed to the incident Required in all reports. Describe anything, or the absence of anything, that contributed to the hazard such as poor housekeeping or poor visibility, using equipment without guards, or the lack of safe work procedures.  FORMTEXT       10. Nature of the serious injury (optional  complete only if there has been an injury)  FORMCHECKBOX  Life threatening or resulting in loss of consciousness  FORMCHECKBOX  Major broken bones in head, spine, pelvis, arms, or legs  FORMCHECKBOX  Major crush injuries  FORMCHECKBOX  Major cut with severe bleeding  FORMCHECKBOX  Amputation of arm, leg, or large part of hand or foot  FORMCHECKBOX  Major penetrating injuries to eye, head, or body  FORMCHECKBOX  Severe (third-degree) burns FORMCHECKBOX  Punctured lung or other serious respiratory condition  FORMCHECKBOX  Injury to internal organ or internal bleeding  FORMCHECKBOX  Injury likely to result in loss of sight, hearing, or touch  FORMCHECKBOX  Injury requiring CPR or other critical intervention  FORMCHECKBOX  Diving illness such as decompression sickness or near drowning  FORMCHECKBOX  Serious chemical or heat/cold stress exposure  FORMCHECKBOX  Other (specify)  FORMTEXT      11. Brief description of the incident Required in Preliminary Report. Briefly, summarize the sequence of events, the unsafe factors, and the resulting injury, if any.  FORMTEXT      12. Corrective actions identified and taken to prevent recurrence of similar incidents Action (Required in Preliminary Report and Interim Corrective Action Report. Update in Full Report, if necessary.)Action assigned to (name and job title)Expected completion date (yyyy-mm-dd)Completed date (yyyy-mm-dd)a)  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      b)  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      c)  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      d)  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      e)  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      13. 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FORMTEXT      14. Persons who carried out or participated in the preliminary investigation RepresentativeNameJob titleSignature (optional)Date signed (yyyy-mm-dd)Employer representative (required) FORMTEXT       FORMTEXT       FORMTEXT      Worker representative (required) FORMTEXT       FORMTEXT       FORMTEXT      Other FORMTEXT       FORMTEXT       FORMTEXT      Other FORMTEXT       FORMTEXT       FORMTEXT      End of report Completing all the sections above satisfies the requirements for a Preliminary Investigation Report and an Interim Corrective Action Report. Note: If this was a simple investigation and all needed corrective actions have been completed within 48hours, the Preliminary and Full Investigation portions of the report can be completed at the same time. If so, you can check both the Preliminary Investigation Report and the Full Investigation Report boxes in section 5 on page 1. As of January 1, 2016, copies of all reports must also be provided to the joint occupational health and safety committee or worker representative, as applicable. 15. Determination of causes of incident Required in Full Report. Analyze the facts and circumstances of the incident to identify underlying factors that led to the incident. Underlying factors include factors that made the unsafe conditions, acts, or procedures in the Preliminary Report possible. Update items from section 9, if needed.  FORMTEXT      16. Full description of the incident Required in Full Report. Use the brief description from the Preliminary Report and update it, if necessary.  FORMTEXT      17. Additional corrective actions necessary to prevent recurrence of similar incidents Additional corrective action (Required in Full Report and Full Corrective Action Report.)Action assigned to (name and job title)Expected completion date (yyyy-mm-dd)Completed date (yyyy-mm-dd)a)  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      b)  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      c)  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      d)  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      18. Persons who carried out or participated in the full investigation RepresentativeNameJob titleSignature (optional)Date signed (yyyy-mm-dd)Employer representative (required) FORMTEXT       FORMTEXT       FORMTEXT      Worker representative (required) FORMTEXT       FORMTEXT       FORMTEXT      Other FORMTEXT       FORMTEXT       FORMTEXT      19. Other relevant workplace parties Company nameContact personContact number or email addressa)  FORMTEXT       FORMTEXT       FORMTEXT      End of report Completing all the sections above satisfies the requirements for a Full Investigation Report and a FullCorrective Action Report. Employers are required to submit full investigation reports to WorkSafeBC within 30 days* of the incident. Reports may be submitted by fax to 604.276.3247 (Greater Vancouver), toll-free fax 1.866.240.1434, or by mail to POBox 5350, Stn Terminal, Vancouver BC V6B 5L5. Do NOT submit a preliminary report unless you have been so directed by a WorkSafeBC officer. * Employers can request an extension from a WorkSafeBC officer, if the full investigation cannot be completed within 30 days. As of January 1, 2016, copies of all reports must also be provided to the joint occupational health and safety committee or worker representative, as applicable.      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