Big Sandy Community & Technical College
ENVIRONMENTAL HEALTH AND SAFETY
Incident Report
TYPE OF INCIDENT: Theft Vandalism Vehicle Violence Fire
Verbal Threat Other-Explain:
LOCATION OF INCIDENT: Campus: Building:
Off-Campus:
DATE/TIME OF INCIDENT: Time: Date:
PERSON MAKING REPORT:
NARRATIVE: Attach additional pages as necessary. Please include all pertinent details.
PEOPLE INVOLVED:
(Name, dept., phone)
1.
2.
3.
4.
5.
6.
INCIDENT DETAILS: (Causal factors: physical, behavioral, equipment-related or loss, work environment, procedural, etc.)
(To be filled out by Safety coordinator)
CORRECTIVE ACTIONS TO BE TAKEN: (Administrative controls, procedural changes, PPE)
(To be filled out by Safety coordinator)
RECEIVED BY:
Big Sandy Community & Technical College
Environmental Health and Safety
Contact:
John Herald: 606-886-76335
Safety Coordinator
Jeannie Howard/McCoy: 606-889-4710
Facilities Management Coordinator