Thompson Rivers University - Hazard/Incident Report Form PART A= Occurence Detals()ea86 Uk on 7 more te fatonig) nat Sto arn yyy dd fat ee [Ciersatnay Clue" TaNea nse” L1 Soeutytlns FT Eniocrana benege Wott insaipare Name of poson ping occurs. DUPECNI SON... TAN, IAQ MANY ere 432.1... vate of curence: 2012 04/044 Bel escinion teccrenaacas: WOVKEr.WAS.WSING.O.Qrinder..On A Screwdriver, Sevew diver, gst. pulled. towards, the..stone. .ketween. the. trol, rest, nd..the shone... Worker. palled..Wis. hands, away, ¢ fore, making..comback..wsita..tthe,.stone., [PAR any Outale naan ures proced rely fo PART) Saaaeaernacaeaa| sunanectinuespoeon:.. DBE, vennaneiss. Sealer, 08 NAHI 12 LN se: ACF susoniompleyoo number. POY. AA......Enplomentstus: Empleo C Sudet CI PraciamiAperenicestip [Contec Viste Deparment (Ades fron employes) WK AACS- Mechanical. Pr A BEM. Datofinadent 2001 oH/04 Time: TIS Gp Whee de teiniden ome: MECHANICAL. shoo... ig Tam 204 Treatment provided: [7] None [] First Aid [] Ambulance (1 Hospital [] Dr 1] Other. Time lost: N (1 - Date Stopped: ae soaiosaton: ALO, Typeatniy 00, Cause ty. MN Fist aor nae NN. Pisa Dalectveaiment: If PART acoso fr sa bier essed Ass (Tea cangt ices ay al ow hy i ce ‘Take tp far ad selec te corel cals 2 Taka Sep 2raing ad sl he corect ne 3: Cl hos sme where tho wo args ‘Viel ate fe consequences of isnt cooing? | Whats he Belnod of Pe corseqience ceded Consider nat coud reasonably have happened 2s | slo heppanng? Corser ths wos ow oF ‘wel a hal ecilyPappened Look athe | ine conan lace. Lok le descriptors ond escipons and choose re one st sual. ‘cheese th ono moe gab, ‘Goss one maa bao. AEM excovena Hap een Lon Nope Consumes Graal Deron CONSEOUENCES Major Destorocenvoiquies | A ened ocr Geaerais)— Wescalveaent 1B Coukdpababiy ccor Winer Fst ett © cots ecu, vty Insignificant Noteatnet Dayo poy ow PART D Corrective Action (Tobe complied by supervisor of area whar cleat occurred with consultation whee posse) erin Again cool mene kon vn ath ha eae of He ans) corr tw cca Hierarchy of Controls Action TakenfRecommended | Whom When | JobNo, 41. limination (remove the hazard) |- Properly adjust too! Mechanics | ASAP Feet poston Uestrictr| estore (name) lavinder ensure initial safety oe ai inspection of grinder agen belore use 2, Subsituion (se an alternative) 3, (solate (separation fom hazard) )Redesig (change equipment or process Adminstration (change work practice) 6. Personal Protective Equipment lie. gloves, gisses, hearing protection) copy tothe OHS Department ~ Safety Oicer) Supervisor Name: DiN\. KOM. AIS... supervisor signature Na. Date: 2012 104 104 (yearinonihiéey) Phone Number:... 13. Date : 2012 JO4 / OM (yeadmontvday) ‘PART E-= Sign Off Pe Employee Signature: “Decne ONES Bar? tc gr Pape ror (reste July 2010 is Reve Apr 2072 ox Reve A203,