Injury or Near Miss Report

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Injury and Near Miss Report
for all students, employees and visitors.

 

This electronic form must be completed for injuries or near miss incidents involving employees, students, and visitors that occur on the job or during BBCC activities/events on or off campus. Form should be completed within 24 hours of an incident.

A near miss is when an unplanned event occurs resulting in no injuries or damages, but had the potential for such. These are important to report as near miss reporting can help us prevent an injury.

The form is electronic only – no hard copy. When you complete the form, press the submit button at the bottom of the page. You should also print a copy for yourself. There is no need to send a hard copy through interoffice mail.

This electronic form is not intended for the reporting of crime incidents. To report a crime, call Campus Safety 509-793-2286.

If the incident results in a fatality, amputation or hospitalization, call Campus Safety at 509-793-2286.

 

Person Initiating this Report:
Please provide as much detail as possible. Starred items are required.

Person Involved or Affected:
Please provide as much information as possible about the person(s) involved in this situation, including their SID if possible.

Describe the incident:

Classification:
Select a level and select an item in that section.
Level 1
Level 2
Level 3

Type of Injuries:
Select at least one item for each section; multiple items can be selected
Injury Description:
Cause of Injury:
Body Part Affected:

Did incident involve any of these departments:
Possible Factors:
Select at least one item for each section; multiple items can be selected
Equipment:
Environment:
Policies/Procedures:
Human Factors:
Supporting Documentation:
This may include photographs, witness statements, etc.

Please do not use the Print, PDF, and Email buttons shown below as they will not print your responses. 
If you wish to print your responses, please do so by the traditional method: File – Print  

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