Public Safety - Supervisor's Incident Investigation Report

an injury or occupational illness

a motor vehicle occurrence

a fire or smoke occurrence

an elevator occurrence

a major equipment failure

other (describe below)

"Other" type of incident: describe.

Name of party #1 to incident (Last Name, First Name)

Name of party #2 to incident (Last Name, First Name)

Name of party #3 to incident (Last Name, First Name)

Provide a brief description of the incident

presence of physical hazard

presence of ergonomic hazard

presence of biological hazard

presence of chemical hazard

presence of psychosocial hazard

Describe the hazards that gave rise to this incident.

hazard not identified

hazard not accurately assessed

no controls in place to address hazard

controls in place inadequate to address hazard

planned controls adequate to address hazard, but not implemented

non-compliance with controls

Describe the tactical errors identified above

Basic causes description

The College's Health and Safety Management System (HSMS) is grounded in the concepts of the internal responsibility system and due diligence.

Defects or deficiencies in the HSMS, including the absence of standards, inadequate standards, or non-compliance with standards, can give rise to incidents.

In which of the following program elements can you identify defects or deficiencies that gave rise to this incident.

Culture and Community

Internal Responsibility System (Duties, Roles & Rights) & Due Diligence

Hazard Identification and Assessment

Monitoring: Planned Inspections & Maintenance

Compliance and Enforcement

Incident Reporting, Investigation & Analysis

Emergency Preparedness

Describe the deficiencies noted in the program elements

FUTURE LOSS DESCRIPTIONS

INSTRUCTION:

Review the descriptions for each category of Future Loss Potential.

Select the appropriate category from the "Future Loss Potential" drop-down below.

If an incident like this one were allowed to happen again, how serious could the loss be next time

If no changes are made to address the causes of this incident, how likely is it that an inccident, such as this, will happen again?

RISK ASSESSMENT MATRIX

Instruction: To identify the appropriate risk category, cross-reference the "Future Loss Potential" category that you selected above, with the "Likelihood" category that you selected above. Select that risk category from the "Risk Assessment" drop-down below.

	Frequent	Probable	Occasional	Remote	Improbable
Critical	HIGH RISK	HIGH RISK	HIGH RISK	MEDIUM RISK	LOW RISK
Severe	HIGH RISK	HIGH RISK	MEDIUM RISK	LOW RISK	LOW RISK
Moderate	HIGH RISK	MEDIUM RISK	LOW RISK	LOW RISK	LOW RISK
Minimal	MEDIUM RISK	LOW RISK	LOW RISK	LOW RISK	LOW RISK
Negligible	LOW RISK	LOW RISK	LOW RISK	LOW RISK	LOW RISK

If no changes are made to address the causes of this incident, considering both the loss potential and the likelihood, what is the risk associated with a future similar incident?

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Public Safety - Supervisor's Incident Investigation Report