Injury Or Near Miss Report Form

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. The 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 in the future.

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.

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.