Injury Or Near Miss Report Form - Big Bend Community College

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.

Your First Name:

Your Last Name:

Your email address:

Location of incident:

Your position/title:

Your phone number:

Date of incident (DD-MM-YYYY)

Time of incident

Person Involved or Affected:

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

Last Name

First Name

Address

Department Supervisor

Select Gender

DOB

Email Address

Relationship to Incident:

Phone Number

SID

Describe the incident:

Please describe the incident as accurately as possible

Witnesses

Classification:

Select a level and select an item in that section.

Type of Injuries:

Select at least one item for each section; multiple items can be selected

Possible Factors:

Select at least one item for each section; multiple items can be selected

Supporting Documentation:

This may include photographs, witness statements, etc.

Choose files to upload

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