Public Stakeholder Incident Reporting Form 1103

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Incident Reporting Form
Instructions for Use
Incidents involving serious injuries or damages (Level I & II incidents) must be reported immediately to the BC Safety Authority by calling 1-866-566-SAFE (7233). Reporting by email or fax is reserved only for incidents involving minor injuries and damages (Level III incidents). ______________________________________________________________________ Incidents requiring immediate emergency response (police, fire, and/or ambulance) are to be reported directly to 911.
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Completed incident reporting forms can be submitted by the following options:
1) E-mail: For Boilers, Pressure Vessels, Refrigeration, Electrical, Elevating Devices, Gas, Amusement Rides, and Passenger Ropeways: Incidents@SafetyAuthority.ca
Click on the Submit by Email button at the bottom of the form.
2) Fax:
For Amusement Rides and Passenger Ropeways only:
Kamloops: 250-377-4406 New Westminster: 778-396-2174 Vernon: 250-549-5602
FRM - 1103-05 (2011-01-28) Public/Stakeholder Incident Reporting Form
Incident Reporting Form
The information on this form is collected to administer the provisions of the BC Safety Standards Act. If you have any questions about the collection, use, or disclosure of this information contact the Records/FOIPP Coordinator for the BC Safety Authority at telephone 1-866-566-SAFE (7233). 04 Date Reported: Time Reported: -. ............................................................................................................................................................................. 6
DETAILS Date Incident Occurred: Address/Location of Incident: Time Incident Occurred:
Type of Premises: Technology Involved: Incident Description: Incident Cause:
If other please specify:
Description of Injuries:
Description of Damages:
Number of People Injured: Number of Fatalities:: Hospitalization Required: Name of Contractor / FSR: Contractor / FSR Phone Number: Yes No
Equipment/Property Damage: Product/Equipment still in service:
Yes Yes
No No
Unit Number: Permit Number:
............................................................................................................................................................................. Notifier Information:
Name: Organization: Contact Phone Number:
By submitting this form I give consent to the BC Safety Authority to verify and disclose the information provided on this form for the purposes consistent with the administration of the BC Safety Standards Act.
Print Form
FRM - 1103-05 (2011-01-28) Public/Stakeholder Incident Reporting Form
Submit by Email