Form 2 (cont’d) Incident Investigation Worker Group: GVTA CUPE 382 CUPE 947 ASA OTHER Date of incident: Time: Witnesses: Name: Title: Name: Title: Preliminary Contributing Factors Full Contributing Factors Preliminary Root Cause(s) Full Root Cause(s) Preliminary Corrective Actions Person Action Date Status Responsible 1. 2. 3. 4. Full Corrective Actions 1. 2. 3. 4. Recommendations to be completed by: (Month/Day/Year) Parties involved in investigation: _________________________________________ ________________ P/VP or Supervisor: Name / Signature Date _________________________________________ ________________ JOHS Worker Rep: Name / Signature Date _________________________________________________ ________________ Other: Name / Signature Date Copies to: Associate Superintendent (via email) P/VP or Supervisor (redacted version to be shared with JOHS Committee) HR (cmerner@sd61.bc.ca) District Behavioral Consultant (dmarchant@sd61.bc.ca) Worker (redacted) File this completed form, in a binder, in a secure location in the administrator’s office.
Form 2 (cont’d) Incident Investigation Worker Group: GVTA CUPE 382 CUPE 947 ASA OTHER Date of incident: Time: Witnesses: Name: Title: Name: Title: Preliminary Contributing Factors Preliminary Root Cause(s) Full Contributing Factors Full Root Cause(s) Preliminary Corrective Actions Person Responsible Action Date Status 1. 2. 3. 4. Full Corrective Actions 1. 2. 3. 4. Recommendations to be completed by: (Month/Day/Year) Parties involved in investigation: P/VP or Supervisor: _________________________________________ ________________ Name / Signature Date JOHS Worker Rep: _________________________________________ ________________ Name / Signature Date Other: _________________________________________________ ________________ Name / Signature Date Copies to: Associate Superintendent (via email) P/VP or Supervisor (redacted version to be shared with JOHS Committee) HR (cmerner@sd61.bc.ca) District Behavioral Consultant (dmarchant@sd61.bc.ca) Worker (redacted) File this completed form, in a binder, in a secure location in the administrator’s office.
VPP-Form-2-Fillable-revised-2016.docx