1. Workplace Safety Concern or Incident Report Form. Reporting Process: Please Read and Follow Questions? Safety or Ext.
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1 1. Workplace Safety Concern or Incident Report Form Reporting Process: Please Read and Follow Questions? Safety or Ext Step 1: Workers must report verbally, directly (in person or by phone) to your administrator or management person in charge at the worksite (teacher in charge, other). If the workplace safety concern or incident is serious, the verbal report must be made immediately. All other safety concerns or incidents should be reported verbally to your administrator or management person in charge without undue delay prior to filing a written report whenever possible. Step 2: File a written safety concern or incident report. Complete this electronic form and click the Submit button at the end. If you are filing a hand filled paper copy of this report form, scan and the completed form to safetyofficer@retsd.mb.ca and to your administrator or management person in charge without delay. 2. Name Please enter the first and last name of the person with the concern or injured party.
2 3. Occupation Please select the best description the occupation or association the person with the concern or injured party has with River East Transcona School Division. Teacher (including school administrators) Educational Assistant Student Services Maintenance - Custodial Services Maintenance - Trades Non-Union Clerk Contractor Visitor Volunteer Library Technician Transportation - Bus Driver Transportation - Maintenance Garage and Stores Student Worker Other 4. Worksite Location - School or Department Injured or concerned person's assigned worksite location. Angus MacKay School (AM)
3 Arthur Day Middle School (AD) Bernie Wolfe Community School (BW) Bertrun E. Galvin Elementary (BEG) Bird's Hill School (BH) Chief Peguis Junior High (CP) College Pierre Elliot Trudeau (CPET) Dr. Hamilton School (DH) Donwood Elementary (DON) Ecole Centrale (EC) Ecole Margaret-Underhill (EMU) Ecole Regent Park (ERP) Emerson Elementary School (EMER) Hampstead School (HAMP) Harold HatcherElementary School (HH) John de Graff Elementary (JDG) John G. Stewart School (JGS) John Henderson Junior High School (JH) John Pritchard School (JP) John W. Gunn Middle School (JWG) Joseph Teres School (JT) Kildonan East Collegiate (KEC) Lord Wolsely Elementary School (LW)
4 Maple Leaf School (ML) Mile Macdonell Colegiate (MILES) Munroe Junior High School (MUN) Murdoch MacKay Collegiate (MUR) Neil Campbell School (NC) Polson School (POL) Prince Edward School (PE) Princess Margaret School (PM) Radisson School (RAD) River East Collegiate (REC) Robert Andrews School (RA) Salisbury Morse Place (SMP) Sherwood School (SHER) Springfield Heights School (SHS) Sun Valley School (SV) Transcona Collegiate (TC) Valley Gardens Middle School (VG) Wayoata Elementary School (WAY) Westview School (WEST) Administration Offices (AO) Student Services Department (Kildare) Maintenence Department (MAINT)
5 Transportation Department (TRANS) Adult Education (McLeod, Transcona, Lombard) 5. Direct Supervisor's Name Enter the name of your direct supervisor here. 6. Local School or Department Administrator's Name Name of the Administrator responsible for the school or department where incident took place. 7. Report Classification Select statement(s) which best describes the workplace safety concern or incident. If serious, call Safety Officer at immediately and / or without delay. Worker seeking medical assessment or treatment for a workplace injury. (Serious) Death or fatality of a worker while working for RETSD workplace. (Serious) Refusal of dangerous work. (Serious) Dangerous occurance (fire, flood, near miss, other) requiring immediate attention. (Serious) Respectful workplace incident (harassment, bullying, worker on worker or other on worker violence) Emotional trauma or mental injury caused by the workplace. First aid administered for a workplace injury. Minor injury, no first aid administered.
6 Student initiated employee abuse (injury caused to workers by students) Safety concern, minor, not requiring immediate attention. Other 8. I have or will be seeking medical assessment or treatment for this a work related injury. If yes, phone the RETSD Safety and Health Officer at immediately after directly speaking to (i.e. verbally reporting your injury) to your administrator. Yes No 9. Safety Concern or Incident Date Enter the date of incident occurrence or the approximate date of the concern. Please input date in format of M/d/yyyy 10. Safety Concern or Incident Details Please describe clearly and concisely the workplace safety concern or injury incident. 11. Number of Concerns or Incidents in Report If reporting more than one incident in this report, please enter the total number of incidents here.
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30/17 MOVED by Trustee Kotyk, (S) Trustee Sodomlak THAT the following minutes be approved, confirmed and adopted as presented:
Page 11 A BOARD MEETING of The River East Transcona School Division was duly called and held on Tuesday, at 6:40 p.m., in the Allen Rouse Room, 589 Roch Street, Winnipeg, Manitoba. TRUSTEES PRESENT: C.
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