Safety Concern & Near Miss Form Supervisor @ Event Report Instructions Reminder: The system does not auto-save, please save frequently to avoid losing data Event Reporting This form should be only used for reporting near miss, safety concerns, and unsafe acts, events, or situations that did not result in an injury or iliness. Near Miss - Incidents that resulted in no injury (inclusive of psychological), but had the potential for causing serious injury, are sometimes called “close calls" or "near misses" Safety Concern - Any condition or practice that may cause a substantial probability of physical (or psychological) harm, property loss and/or environmental impact Unsafe Act - Actions/behaviours that result in accidents, property loss, or harm to the environment, putting the life, health, or safety of another person directly in danger Employee Reporting Information Employee Reporting * Please provide your contact email address Organization Home Location Date of Incident * Date Reported * Holand, Mark (E21987) mark_holand@bertc.bc.ca BC Rapid Transit Co. Ltd(BCR) Operations & Maintenance Centre 1(070) 2026/01/22 2026/01/22 Self Reporting Number Employee Job Type Employee Contact Phone Number Department Incident Time Time Reported * 75625 Control Operator 80 (BU023) 236-994-3376 Control Operations(74300) 06:30 12:33 000204