Langley Schools, Violent Incident Report (Page 2 of 2) in pdf

VIOLENT INCIDENT INVESTIGATION – PART 2

(To be completed by Supervisor)

If this is WORKPLACE MISCONDUCT call HUMAN RESOURCES IMMEDIATELY.

STOP!

DO NOT investigate locally. Read the instructions and definitions carefully.

Definitions:

INSTRUCTIONS for Administrator/Supervisor

1. Administrator/Supervisor to read Definitions and

Workplace Misconduct, Improper Activity or Behaviour: “includes: the attempted or actual exercise

determine if the incident reported is best characterized

by a worker towards another worker of any physical force so as to cause injury, and includes any

as Workplace Misconduct or Workplace Violence.

threatening statement or behaviour which gives the worker reasonable cause to believe he or she is at risk

of injury”. (see WorkSafeBC OH&S Regulation 4.24 for full definition.)

2. If Workplace Misconduct, stop here and immediately

forward the report to the Assistant Superintendent of

Workplace Violence: “Means the attempted or actual exercise by a person, other than a worker, of any

Human Resources. Do not complete an investigation

physical force so as to cause injury, and includes any threatening statement or behaviour which gives the

locally.

worker reasonable cause to believe he or she is at risk of injury.” (See WorkSafeBC OH&S Regulation

4.27 for full definition).

3. If Workplace Violence, assemble an investigation

Team: 1 Administrator/Supervisor and 1 Worker Health

Note: Worker as defined in the Workers’ Compensation Board Act, includes an employee or supervisor

and Safety Representative (typically of the same

working at the time in question for the same employer or for a different employer.

employee group as the employee involved).

Investigation Team: (Name / Position)

4. Complete one investigation report per incident reported.

Submit to Director, Health and Safety.

5. Investigations to be completed and submitted within 72

hours of the incident.

Investigation Team’s Summary of Incident:

(attach supporting documents as required. Include sequence of events, sketch, equipment, etc.

School/Site:

Incident Date:

Cause / Contributing Factor

School Administrator / Supervisor / Assistant Superintendent to Complete:

Corrective Action(s) Taken:

Actioned to:

Completion Date:

Checklist of Persons Notified: (if applicable)

Assistant Superintendent

Student’s Parent/Legal Guardian

Relevant Staff

Transportation

RCMP

RCMP Attended:

Yes

Investigating Police Officer:

Case Number:

Outcome

Date

Recommended Corrective Action(s):

(Attach supporting documents as required)

•

Signature:

(Principal / Supervisor)

Print Name:

Date:

Personal information on this form is collected by School District #35 (Langley) for the purpose of investigation, correction and prevention of violent incidents in the

workplace and the administration of the Health and Safety Program. Personal information on this form is collected and will be protected in accordance with the

Freedom of Information and Protection of Privacy Act.

For further information, please contact the Director, Health and Safety at School District #35 (Langley), 4875 – 222 Street, Langley, BC V3A 3Z7

Revised Dec/2010