PSC38 Forms For The Maples Adolescent Treatment Centre

Obtained by Bob Mackin via Freedom of Information 2010goldrush@gmail.com twitter.
com/bobmackin
JOINT INCIDENT INVESTIGATION FORM PSC38 Ministry Ministry of Children and Family Development
s.22
.
Tel. # 604 660-5864 Location Crossroads First Name
s.22
Date of Report November 2, 2010 File No. Hours Worked in Previous 24 Hour Period
Last name of Injured (or ill) Person Years of Service

s.22
Time on Present Job
Occupation Nurse
8
Time 4:15 pm
Incident Location (Dept. or Area) Crossroads
Date of Incident November 1, 2010
Incident Category Jcheck)
[gIlnjury or Illness
Equipment Malfunction
0 Motor Vehicle
Severity of Injury or Illness -<cheek)
[gI No Injury or First Aid Only
I0
0 Property Damage
Fire
D Other
Time Loss
Medical Treatment
I0
Fatal *
Nature of Injury or Illness s.79 YCJA Punched two to three times on forehead Swelling and redness above right eye. Employee sent home after ice applied and tylenol administered, declined offer of being driven. Left unit approximately one hour after incident occurred.
Description of Incident or Employee's Account of Occupational Disease (eg. RSI)

s.79 YCJA
Were Written Safe Work Procedures Established and Available? N/A 0 Yes IZI No 0 Basic Cause (and Contributory Factors)
Were they Adequate? Yes [gI No
N/A
Were these Safe Work Procedures used in Training? NoD N/AO
EXPLAIN FULLY UNSAFE CONDITIONS
s.79 YCJA
Phase 1 Page 1 CFD-2013-00082
Corrective Measures Taken and/or Recommended

s.79 YCJA
Corrective Action Referred To:
NA
Date To Be Completed By:
NA
Additional Comments or Observations. Where applicable give details of makes & models of machines, equipment, tools, structures, etc., involved in this incident.
NA
Name(s) & occupations of person(s) who investigated incident: Name Occupation
Roy Lucken
Nurse SPO
Phone 604-660-5864 604-775-0462
/1
.. _ _ _ _
of WorKers' Representative Date Name(s) of Witness(es) (include phone number): Name
s.15, s.22
/I""
Signature bfi:mployer Representative Phone 604-660-5864
IVQV
0:, /Ifi
Date
* If fatal, ensure you contact the local WCB office as per WCB HIS Regulation #6:02(a), local BCGEU office and the Human Resource Department. Keep Original and Forward Copy To: (1) Ministry Designate; (2) BCGEU Area Office; (3) Local OSH Committee; & (4) Local WCB office
JOINT INCIDENT INVESTIGATION FORM PSC38 Ministry Ministry of Children and Family Development Tel. # 604660-5800 Location 3405 Willingdon Ave Burnaby First Name Occupation Office Assistant Date of Report September 14,2010 File No. Hours Worked in Previous 24 Hour Period Time
Last name of Injured (or ill) Person

s.22
Years of Service
s.22
Time on Present Job
Incident Location (Dept. or Area) Clinical Records file room Incident Category (check) Injury or Illness
Date of Incident September 2010
0 Equipment Malfunction
0 Motor Vehicle
Severity of Injury or Illness (check)
No Injury or First Aid Only
I0
0 Property Damage
Fire
Other Time Loss
Medical Treatment
I0
Fatal *
Nature of Injury or Illness tendinitise in right shoulder. Moving boxes in file room
Description of Incident or Employee's Account of Occupational Disease (eg. RSI) When s.22 needed to work on a clients file ,he would have to go to the file room and lift the box off of the shelf to retrieve the file.The files have been in boxes for about 1 month awaiting the move of the department
Were Written Safe Work Procedures Established and Available? NoD N/AO Basic Cause (and Contributory Factors)
Were they Adequate? NoD N/AO
Were these Safe Work Procedures used in Training? YesO NoD
Corrective Measures Taken and/or Recommended When employee reported that the boxes were to heavy 10 to 14 kg, he was told to put up a sign advising staff that the boxes were heavy to make sure to use correct lifting procedures He was also told to order a sturdier step stool to stand on so that he would not have a problem lifting boxes on the top shelf
Name{s) & occupations of person{s) who investigated incident: Name Occupation Barbara Susheski Business Administrator
Phone 6046605581
Signature of Workers' Representative
Date
Signature of Employer Representative
Date
Name{s) ofWitness{es) (include phone number): Name
* If fatal, ensure you contact the local WCB office as per WCB HIS Regulation #6:02{a), local BCGEU office and
the Human Resource Department. Keep Original and Forward Copy To: (1) Ministry Designate; (2) BCGEU Area Office; (3) Local OSH Committee; & {4} Local W CB office
JOINT INCIDENT INVESTIGATION FORM

PSC 38 Ministry Tel. # Location Date of Report
Ministry of Children and Family Development
604660-5843
Maples Response Unit

First Name
July 22, 2010

File No.

s.22
Years of Service
s.22
Time on Present Job
Occupation
Hours Worked in Previous 24 Hour Period
Child Care Counselor
7
Time
Incident Location (Dept. or Area)
Response Kitchen
Incident Category (check)
Date of Incident
July 15, 2010
1:30 pm
IZIlnjury or Illness
D Equipment Malfunction
D Motor Vehicle
D Property Damage
D Fire D Other
Severity of Injury or Illness (check) Nature of Injury or Illness
IZI No Injury or First Aid Only
I D Medical Treatment
o Time Loss I 0
Fatal *
Sprained right knee.
Worker s.22 halted step to step backward and his heel temporarily stuck to the floor, leading to a painful twinge in right knee.
Were Written Safe Work Procedures Established and Available? No D N/A D Yes IZI Basic Cause (and Contributory Factors)
Were they Adequate? Yes
IZI
No
N/AD
Were these Safe Work Procedures used in Training? N/A IZI Yes D No D
Stop/start movement on a sticky floor.
Direct staff to clean floor when it is sticky or dirty (beyond the daily cleaning that it receives).
N/A
N/A
Additional Comments or Observations. Where applicable give details of makes & models of machines, equipment, tools, structures, etc., involved in this incident. N/A
Dan Luoma Stephen Sjoberg
Child Care Counselor Social Program Officer
Phone (604) 660-5864 (604) 660-5846
/
Signature of Workers' Representative Datet "lure
-- 07
ckt/----;I'22-----i
yer Representative Voat
Name( s) of Witness( es) (include phone number): Name
'
JOINT INCIDENT INVESTIGATION FORM PSC 38 Ministry Tel. # Location Date of Report
604660-5843
Response Unit
First Name
July 22, 2010

File No.

s.22
Years of Service
s.22
Time on Present Job
Occupation
7
Time
Response Kitchen
Incident Category (check) _(check) Nature of Injury or Illness
Date of Incident
June 22, 2010
1:00 pm
[g] Injury or Illness
0 Motor Vehicle
0 Property Damage
Fire
o Other
Severity of Injury or Illness
[g] No Injury or First Aid Only
I0
Medical Treatment
o Time Loss I 0
Fatal *
Sprained right thumb

s.22
was lifting the food cart and sprained her right thumb while doing so.
Were Written Safe Work Procedures Established and Available? No 0 N/A 0 Yes [g] Basic Cause (and Contributory Factors)
Were they Adequate? Yes No
N/A
Were these Safe Work Procedures used in Training? Yes 0 No 0 N/A [g]
Weight of food cart and improper moving technique.
None required.
N/A
Date To Be Com pleted By:
NI A
Additional Comments or Observations. Where applicable give details of makes & models of machines, equipment, tools, structures, etc., involved in this incident. N/A
Name(s) & occupations of person(s) who investigated incident: Name Occupation Dan Luoma Child Care Counselor
Stephen Sjoberg
Social Program Officer
Phone (604) 660-5864 (604) 660-5846
VV---'
Date
i
__
Name(s) of Witness(es) (include phone number): Name
* If fatal, ensure you contact the local WCB office as per WCB HIS Regulation #6:02(a), local BCGEU office and the Human Resource Department.
Keep Original and Forward Copy To: (1) Ministry Designate; (2) BCGEU Area Office; (3) Local aSH Committee; & (4) Local WCB office

PSC38 Ministry Ministry of Children and Family Development Tel. # 604 660-5846 Location 3405 Willingdon Ave., Burnaby, B.C. First Name Occupation Date of Report 2011-12-16 File No. Hours Worked in Previous 24 Hour Period 7.5 Time 9:00 hrs

s.22
Years of Service
s.22
Time on Present Job
Social Worker
Incident Location (Dept. or Area) Response
Date of Incident 201112-07
0 Injury or Illness
0 Motor Vehicle
Property Damage
Fire
0 0
Other Time Loss 1 0 Fatal *
No Injury or First Aid Only 1 0 Medical Treatment
Nature of Injury or Illness Twisted left ankle. Bruised right shoulder and bruised left knee (medial)
Description of Incident or Employee's Account of Occupational Disease (eg. RSI) As s.22 entered her office at the beginning of her work day, she tripped and fell on some pillows that had been left inside her office near the doorway entrance. s.22 fell forward, sustaining the damage as listed above. s.22 was bruised and shaken and saw our first-aid attendant and then later saw her community doctor.
Were Written Safe Work Procedures Established and Available? Yes0 NoO N/AO
Were they Adequate? Yes0 NoO N/AO
Were these Safe Work Procedures used in Training? YesO No0 N/AO
Basic Cause (and Contributory Factors) EXPLAIN FULLY UNSAFE CONDITIONS Obstacles left in the entraance area to s.22 office. These pillows were left on the floor by Midnight staff who forgot to pick them up after their rest breaks the preceding evening. The Program Coordinator has followed up with the Midnight staff with directions that this is to not occur again. s.22 had no way of knowing that these pillows would be on the floor in front of her as she entered her office and therefore she tripped on them and could have been hurt much worse than she was.
Response PC has directed M staff and all other staff working in Response to not use s.22 office at any time and certainly not for purposes like rest breaks. The Response PC has identified other areas where this sort of thing would be more appropriate.
Stephen Sjoberg
Dec. 8,2011
Phone
Stephen Sjoberg Arthur Bates
SP028 SP021
604-660-5846 604-775-0462
Date
Representative
aC-/64
Date
Keep Original and Forward Copy To: (1) Ministry Designate; (2) BCGEU Area Office; (3) Local OSH Committee; & (4) Local WeB office
.COLUMBIA
BRITISH
I Ministry of Children
and Family Development
Joint Incident Investigation Form
The personal information requested on this form is collected under the authority of and will be used for the purpose of administering the Child, Family and Community Service Act (CFCS Act). Under certain circumstances, the collected information may be subject to disclosure as per the CFCS Act and/or the Freedom of Informailon and Protection of Privacy Act. Any questions about the collection, use or disclosure of this infonnation should be discussed with the social worker involved with this agreement. TELEPHONE NUMBER LOCATION . REPORT DATE (YYYY-MM-DD)
1604 660-5841
I I Cottage One
FIRST NAME
12011-11-18
IIRLENO
HOURS WORKED IN PREVIOUS 24-HOURS
LAST NAMEOF INJURED (OR ILL) PERSON
'YEARS OF SERVICE
s.22
TIME ON PRESENT JOB OCCUPATION
s.22
I 1.. -1_C_h_ild_C_a_re_c_o_u_ns_e_l_or _ _ _ _ _ _ _---'11 7 _

INCIDENT DATE (YYYY-MM-DD) TIME
INCIDENT LOCATION (DEPARTMENT OR AREA)
12011-11-15
INCIDENT CATEGORY (CHECK)
1110:00
AM
C, PM
IZllnjury or Illness DFire
DOther
D Motor Vehicle
D Property Damage
SEVERITY OF INJURY OR ILLNESS (CHECK)
IZl No Injury or First Aid Only D Medical Treatment
DTime Loss
DFatal
I scraped knee and bruised hand

DESCRIPTION OF INCIDENT OR EMPLOYEE'S ACCOUNT OF OCCUPATIONAL DISEASE (E.G. RSI)
NATURE OF INJURY OR ILLNESS
s.22
explained she slipped and fell on the linoleum floor at the base stairs in cottage one as her feet were
WERE THEY ADEQUATE? WERE THESE SAFE WORK PROCEDURES USED IN TRAINING?
wet.
I eYes I C' Yes C No ., N/A I Slippery shoes from wet ground outside
BASIC CAUSE (AND CONTRIBUTORY FACTORS) CORRECTIVE MEASURES TAKEN AND / OR RECOMMENDED
WERE WRITTEN SAFE WORK PROCEDURES ESTABLISHED AND AVAILABLE?
No
t!, N/A
I eYes
C, No
(...) N/A
Recommend: improving the lighting at the base of the stairs

CORRECTIVE ACTION REFERRED TO: TO BE COMPLED BY (YYYY-MM-DD)
____________________
ADDITIONAL COMMENTS OR OBSERVATIONS. WHERE APPLICABLE GIVE DETAILS OF MAKES AND MODELS OF MACHINES, EQUIPMENT, TOOLS, STRUCTURES, ETC. INVOLVED IN THIS INCIDENT.
Observations: Lighting in the inside stairwell is borderline - satisfactory., the two rows of slip treads on the top of the stairs closest to the outside edge are either badly worn or varnished over - making most of them ineffective as targets for traction. Several of the bull noses on the stairs are chipped away.
NAME(S) AND OCCUPATION(S) OF PERSON(S) WHO INVESTIGATED INCIDENT:
Name
Occupation
Phone
Dan Aitken Mark Hadath

SIGNATURE OF WORKER'S REPRESENTATIVE
Program Coordinator
604 660-5841
BCGEU Shop Steward

DATE (YYYY-MM-DD)
///
v
604 660-5843
Itfc?IILlf/d' / I I I
CF0649_{11/03) Security Classification: PUBLIC
'-.-.....---
It:TtlIi';c I
r
Page 1 of2
Name
NAME(S) OF WITNESS(ES).INCLUDE PHONE NUMBER:
Phone Phone
Name
N/A
Security Classification: PUBLIC
Page 2 of2

PSC38 Ministry Tel. # Location Date of Report
604660-5865
3405 Willingdon Ave., Burnaby, B.C.

First Name
2011-09-13
File No.

s.22
Years of Service
s.22
Time on Present Job
Occupation
Nurse 4
6 hrs. 20 min.
Time
Crossroads
Date of Incident
2011-09-10
1420
Injury or Illness
0 Motor Vehicle
Severity of Injury or Illness _(check) Nature of Injury or Illness
0 Property Damage
Fire
Other Time Loss
Medical Treatment
I0
Fatal *
Bruising and swelling to bridge of nose.

s.79 YCJA
one staff and s.79 YCJA at the other staff, punching her in the face several times. s.79 YCJA 2nd staff punching her and knocking her head into the wall. 3rd staff punching her in the face and knocking her glasses to the ground. s.79 YCJA
s.79 YCJA s.79 YCJA s.79 YCJA
Were Written Safe Work Procedures Established and Available? No 0 N/A 0 Yes Basic Cause (and Contributory Factors)
N/A
s.79 YCJA
s.79 YCJA
OnOSH Meeting
TBA
Name(s) & occupations of person(s) who investigated incident: Name Occupation Louise Brown N7 Bronwyn Armstrong CCC Christine Brisebois N4
Phone 604-660-5865 604-660-3878 604-660-5843
PtJ'1N
Signatw-e of Workers'
6<pi, IVIii
te
,o/[)
Signature of Em ployer Representative Date Phone 604-660-5503 604-660-5820

s.15, s.22
Keep Original and Forward Copy To: (1) Ministry Designate; (2) BCGEU Area Office; (3) Local OSH Committee; & (4) Local WeB office
JOINT INCIDENT INVESTIGATION FORM PSC 38 Ministry Ministry of Children and Family Development Tel. # 604 660-5865 Location 3405 Willingdon Ave., Burnaby, B.C. First Name Occupation Date of Report 2011-09-13 File No. Hours Worked in Previous 24 Hour Period

s.22
Years of Service
s.22
Time on Present Job
Childcare Counsellor
Date of Incident 2011-09-10
7.5
Time 1420
Incident Location (Dept. or Area) Crossroads I Incident Category (check) IZ!lnjury or Illness
0 Motor Vehicle
0 Property Damage
Fire
Other
No Injury or First Aid Only lIZ! Medical Treatment
IZ! Time Loss
I0
Fatal *
Nature of Injury or Illness Back of head sore, loss of consciousness for approximately 10 seconds, sore arms and neck.
\ Description of Incident or Employee's Account of Occupational Disease (eg. RSI)

s.79 YCJA
one staff ands.79 YCJA at the other staff, punching her in the face several times. 2nd staff punching her and knocking her head into the wall. s.79 YCJA 3rd staff punching her in the face and knocking her glasses to the ground. s.79 YCJA
Were Written Safe Work Procedures Established and Available? Yes IZ! No 0 N/A 0 Basic Cause (and Contributory Factors)
Were they Adequate? Yes IZ! No
N/A
Were these Safe Work Procedures used in Training? N/A 0 Yes IZ! No 0
s.79

s.79 YCJA
OSH Meeting
TBA
Name(s) & occupations of person(s) who investigated incident: Name Occupation Louise Brown N7 Bronwyn Armstrong CCC Christine Brisebois N4
Phone 604-660-5865 604-660-3878 604-660-5843
Srlw!l/
s.15, s.22
5\ WI 1 Ette':
Phone 604-660-3878 604-660-5820
Representauve
PI IA
' Date"
I
* If fatal, ensure you contact the local WCB office as per WCB HIS Regulation #6:02(a), local BCGEU office and the Human Resource Department. Keep Original and Forward Copy To: (1) Ministry Designate; (2) BCGEU Area Office; (3) Local OSH Committee; '
& (4) Local WCB office
JOINT INCIDENT INVESTIGATION FORM PSC38 Ministry Tel. # Location Date of Report
604660-5865

First Name
2011-09-13
File No.

s.22
Years of Service
s.22
Time on Present Job
Occupation
7.5
Time
Crossroads
Date of Incident
2011-09-10
1420
D Injury or Illness
D Motor Vehicle
D Property Damage
D Fire IZ! Other

IZ! Time Loss I D Fatal *
IZ! No Injury or First Aid Only lIZ! Medical Treatment
Punched on left side of face. Fist grazed as staff able to move back. Glasses knock from her face on onto the floor. Glasses were not broken.

s.79 YCJA
one staff and s.79 YCJA at the other staff, punching her in the face several times. 2nd staff punching her and knocking her head into the wall. s.79 YCJA 3rd staff punching her in the face and knocking her glasses to the ground. s.79 YCJA
Were Written Safe Work Procedures Established and Available? Yes IZ! No D N/A D Basic Cause (and Contributory Factors)
IZ!
No
N/A
Were these Safe Work Procedures used in Training? N/A D Yes IZ! No D
s.79

s.79 YCJA
OSH Meeting
TBA
Louise Brown Bronwyn Armstrong Christine Brisebois
cce
N4
N7
Phone 604-660-5865 604-660-3878 604-660-5843
fJdfif1
\J
c5ept:
Da'te Phone 604-660-3878 604-660-5503
_ __
Signature-i>f Workers' Representative
Name(s) ofWitness(es) (include phone number): Name

s.15, s.22
* If fatal, ensure you contact the local WCB office as per WCB HIS Regulation #6:02(a), local BCGEU office and
the Human Resource Department. ' Keep Original and Forward Copy To: (1) Ministry Designate; (2) BCGEU Area Office; (3) Local OSH Committee; & (4) Local WCB office \
PSC38 Ministry Ministry of Children and Family Development Tel. # 604 660-5864 Location 3405 Willingdon Ave., Burnaby, B.C. First Name Occupation
CC
Date of Report 2011-07-20 File No. C-2011 07 -19 Hours Worked in Previous 24 Hour Period 7.5 Time 1045

s.22
Years of Service
s.22
Time on Present Job
Incident Location (Dept. or Area) Crossroads Program
0 Motor Vehicle
Property Damage
Fire
0 0
Other Time Loss
I0
Medical Treatment
I0
Fatal *
Nature of Injury or Illness Soreness to right shoulder and lower right side muscles.

s.79 YCJA s.79 YCJA
Restrained by employee with assistance from other staff
Were they Adequate? Yes IZI No
N/A
Were these Safe Work Procedures used in Training? Yes IZI No 0 N/A 0

s.79 YCJA

s.79 YCJA
aSH meeting
NA
NA
Phone
RPN Roy Lucken Bronwynn Armstrong CC
604-660-5864 604-660-5861
Signature of Workers'
Jut \} IfD/t I
Date'
I
.;g
Date

s.15, s.22
Phone
604-660-5864 604-660-5864
Keep Original and Forward Copy To: (1) Ministry Designate; (2) BCGEU Area Office; (3) Local OSH Committee; & (4) Local WCB office
PSC 38 Ministry Ministry of Children and Family Development Tel. # 604 660-5865 Location 3405 Willingdon Ave., Burnaby, B.C. First Name Occupation Date of Report April 28, 2011 File No. Hours Worked in Previous 24 Hour Period

s.22
Years of Service
s.22
Time on Present Job
7.5
Time 1840
Incident Location (Dept. or Area) Crossroads Program
Date of Incident July 4, 2011
0 Motor Vehicle
I0
0 Property Damage
Fire
0 0
Other Time Loss
Medical Treatment
I0
Fatal *
Nature of Injury or Illness Long scratch down back and left side of neck. Abrasions on right knee cap. Stiffness and soreness of torso, shoulders/armpit area and inner thighs.

s.79 YCJA s.79 YCJA
, both
s.79 YCJA
fell to the ground.
s.79 YCJA
punched staff several times in head, back, shoulder and neck area.
s.79 YCJA
N/A
Were these Safe Work Procedures used in Training? Yes IZI No 0 N/A 0

s.79 YCJA

s.79 YCJA
- refer to aSH committee
Shiftheads to advise staff and refer to aSH meeting
July 12, 2011
Name(s) & occupations of person(s) who investigated incident: Name Occupation Louise Brown N7 Arthur Bates SPO
Phone 6046605865 604-775-0462
nat' e of Workers' Representative
Representative
"""

s.15, s.22
Phone 604-561-3357 604-660-5864
Keep Original and Forward Copy To: (1) Ministry Designate; (2) BCGEU Area Office; (3) Local OSH Committee;

PSC 38 Ministry Ministry of Children and Family Development Tel. # 604 660-5800 Location Maples Adolescent Treatment Centre First Name Occupation Date of Report June 15, 2011 File No. Hours Worked in Previous 24 Hour Period

s.22
Years of Service
s.22
Time on Present Job
office assistant
Date of Incident June 14, 2011
7
Time 2:15 pm
Incident Location (Dept. or Area) administration area I Incident Category (check) Injury or Illness
D Motor Vehicle
Property Damage
Fire
o Other
D Time Loss I D Fatal *
I0
Medical Treatment
Nature of Injury or Illness scraps on both knees and elbow (carpet burn) (n() blood)
Description of Incident or Employee's Account of Occupational Disease (eg. RSI) Employee was inserting filing into 6 boxes, he had 3 boxes on his cart, 2 boxes in front of the desk next to him in line with the cart out of way of the walking path. He placed one box in front of the cart on the floor, in the walking path . Employee got up from his desk to go some where and tripped over the box he placed on the floor.
Were Written Safe Work Procedures Established and Available? Yes No 0 N/AO
Were they Adequate? NoO N/AO
Were these Safe Work Procedures used in Training? NoO N/AD
Basic Cause (and Contributory Factors) Employee placing box in the walking path
Donot place boxes on the floor in the path that staff may be walking Pay attention to where you are walking
s.22
and has taken the OSH training
Phone
Barbara Susheski Bronwyn Armstrong
administrative Officer child care counsilor
6046605581 6046605861
Si9 natllre' of
fbll l
Date Signature of Employer Representative Date

s.15, s.22
Phone
6046605807

PSC38 Ministry Ministry of Children and Family Development Tel. # 604660-5865 Location 3405 Willingdon Ave., Burnaby, B.C. First Name Occupation Date of Report 2011-05-20 File No. Hours Worked in Previous 24 Hour Period 7.5 Time 2120

s.22
Years of Service
s.22
Time on Present Job
Incident Location (Dept. or Area) Crossroads Program I Incident Category (check) 1ZIinjury or Illness
0 Motor Vehicle
1ZI Property Damage
Fire
Other
No Injury or First Aid Only 11ZI Medical Treatment
1ZI Time Loss
I0
Fatal *
Nature of Injury or Illness Swollen and sore jaw, pain in back,right shoulder and arm.

s.79 YCJA
charged at staff #1 from the back with fists drawn punching her twice in the face causing her to fall to the ground. s.79 YCJA
s.79 YCJA s.79 YCJA
a bear hug #2's thumb pulling it back against the wall

s.79 YCJA s.79 YCJA
s.79 YCJA s.79 YCJA s.79 YCJA s.79 YCJA
staff smashed staff #2 head

s.79 YCJA
threw the computer at staff #2.
Were Written Safe Work Procedures Established and Available? Yes 1ZI No D N/A 0 Basic Cause (and Contributory Factors)
s.79 YCJA
Were they Adequate? Yes 1ZI No
N/A D
Were these Safe Work Procedures used in Training? N/A 0 Yes 1ZI No 0
- staff voiced concern about working with an all female team
Corrective Measures Taken and/or Recommended CISO arranged for May 25 for staff involved in incident
s.15, s.79 YCJA
OSH meeting
CISO to be completed May 25 Other recommendation TBA
Additional Comments or Observations. Where applicable give details of makes & models of machines, equipment, tools, structures, etc., involved in this incident. Staff phone Model #M5316 Computer Monitor Computer Keyboard
Name(s) & occupations of person(s) who investigated incident: Name Occupation N7 Louise Brown Bronwyn Armstrong CC
Phone 604-660-5865 604-660-5861
.( (ID5I3)
Date Name(s) of Witness(es) (include phone number): Name
s.15, s.22
_ _
of Em ployer Representative
Date
Phone 604-660-5820 604-660-3878

PSC 38 Ministry Ministry of Children and Family Development Tel. # 604660 ..5865 Location 3405 Willingdon Ave., Burnaby, B.C. First Name Occupation Date of Report 2011-05..20 File No. Hours Worked in Previous 24 Hour Period 7.5 Time 2120

s.22
Years of Service
s.22
Time on Present Job
Nurse 4
Date of Incident 2011-05..17
Incident Location (Dept. or Area) Crossroads Program I Incident Category (check) IZ!lnjury or Illness
0 Motor Vehicle
IZ! Property Damage
Fire
Other
No Injury or First Aid Only lIZ! Medical Treatment
IZ! Time Loss
ID
Fatal *
Nature of Injury or '"ness Swelling of Right thumb pad, pain in neck area with movement, slight goose egg on right side of head.

s.79 YCJA
charged at staff #1 from the back with fists drawn s.79 YCJA punching her twice in the face causing her to fall to the ground.
s.79 YCJA s.79 YCJA
bear hug on #2's thumb pulling it back against the wall

s.79 YCJA s.79 YCJA

s.79 YCJA
Were Written Safe Work Procedures Established and Available? N/A D Yes IZ! No 0 Basic Cause (and Contributory Factors)
Were they Adequate? Yes IZ! No
N/A
Were these Safe Work Procedures used in Training? Yes IZ! No D N/A D
s.79 YCJA
.. staff voiced concern about working with an all female team
-CISO arranged for May 25 for staff involved in incident
s.15, s.79 YCJA
aSH meeting
CISO completed May 25 Other recommendation TBA
Staff phone Model #M5316 Computer Monitor Computer Keyboard
Phone
Louise Brown Bronwyn Armstrong
N7 CC
604-660-5865 604- 660-5861
{(!ai31
r entative Date

s.15, s.22
Phone
604-660-5820 604-660-3878
the Human Resource Department. Keep Original and Forward Copy To: (1) Ministry Designate; (2) BCGEU Area Office; (3) Local aSH Committee;

604 660-5865

First Name
2011-05-20
File No.

s.22
Years of Service
s.22
Time on Present Job
Occupation
7.5
Time
Crossroads Program
Date of Incident
2011-05-17
2120
[8] Injury or Illness
D Motor Vehicle
[8] Property 0 Fire

Damage
Other
I [8] Medical Treatment
[8] Time Loss
I0
Fatal *
Right elbow and shoulder joint painful with movement.

s.79 YCJA
charged at staff #1 from the back with fists drawn punching her twice in the face causing her to fall to the ground. s.79 YCJA
s.79 YCJA s.79 YCJA
a bear hug #2's thumb pulling it back against the wall

s.79 YCJA s.79 YCJA

s.79 YCJA
Were Written Safe Work Procedures Established and Available? No D N/A 0 Yes [8] Basic Cause (and Contributory Factors)
s.79 YCJA
[8]
No
N/A
Were these Safe Work Procedures used in Training? No 0 N/A 0 Yes [8]
- staff voiced concern about working with an all female team
CISD arranged for May 25 for staff involved in incident
s.15, s.79 YCJA
aSH meeting
CISD to be completed May 25 Other recommendation TBA
Staff phone Model #M5316 Computer Monitor Computer Keyboard
Phone
Louise Brown Bronwyn Armstrong
N7 CC
604-660-5865 604-660-5861
l{/08L31
Date Date Name(s) of Witness(es) (include phone number): Name
s.15, s.22
Phone
604-660-5864 604-660-3878
the Human Resource Department. Keep Original and Forward Copy To: (1) Ministry Designate; (2) BCGEU Area Office; (3) Local OSH Committee; & (4) Local WCB office

PSC38 Ministry Ministry of Children and Family Development Tel. # 604660-5865 Location 3405 Willingdon Ave., Burnaby, B.C. First Name Occupation Date of Report April 28, 2011 File No. Hours Worked in Previous 24 Hour Period 7.5 Time 1700 hrs.

s.22
Years of Service
s.22
Time on Present Job
Date of Incident April 26, 2011
Incident Location (Dept. or Area) Crossroads Program I Incident Category (check) IZIlnjury or Illness
Severity of Injury or Illness {check)
IZI No Injury or First Aid Only I D Medical Treatment

s.22
0 Motor Vehicle
0 Property Damage
Fire
Other Time Loss
I D Fatal *
Nature of Injury or Illness During 'a restraint the base of
right thumb was injured causing pain and swelling.

s.79 YCJA s.79 YCJA
injuried her right thumb.
The area at the base of the right thumb was painful and swollen.
Were Written Safe Work Procedures Established and Available? N/A D Yes IZI No 0 Basic Cause (and Contributory Factors)
IZI
No
N/A
Were these Safe Work Procedures used in Training? N/A D Yes IZI No 0
s.79 YCJA
Corrective Measures Taken and/or Recommended Several members involved in the restraint feel that a CISO will be helpful.
s.79 YCJA
aSH meeting
CISO scheduled for May 4,2011 .. Completed Other recommendations TBA
Name(s) & occupations of person(s) who investigated incident: Name Occupation Louise Brown N7 Arthur Bates spa
Phone 604.. 660.. 5865 604-775-0462

s.15, s.22
Phone 604-660-5864 604-660-5864 604-660-5843 604-660-5864

604 660-5865

First Name
2011-04-12
File No.

s.22
Years of Service
s.22
Time on Present Job
Occupation
Nurse 5
7.5
Time
Crossroads
Date of Incident
2011-04-09
1900 hrs.
D Motor Vehicle
D Property Damage
D Fire D Other
IZI Time Loss I
D No Injury or First Aid Only
IIZI Medical Treatment
D Fatal *
Broken nose with possible concussion.
Description oflncident or Employee's Account of Occupational Disease (eg. RSI)
s.79 YCJA
staff causing severe bleeding from the nose

Were Written Safe Work Procedures Established and Available? N/A D Yes IZI No D Basic Cause (and Contributory Factors) Were they Adequate? Yes IZI No
s.79 YCJA
head butted one of the male

s.79 YCJA
N/AD
Were these Safe Work Procedures used in Training? N/A D Yes IZI No D
s.79 YCJA
If proper escort technique was used head butting could not have occurred.

s.79 YCJA
CISD completed on April 20, 2011 Dutch door for main office (would dutch door in nursing station fit Crossroads office door) Refresher courses in the hands on component of NVCI done every 6 months Personal safety devices Code policy
s.79 YCJA
aSH Meeting

s.79 YCJA
CISD completed on April 20,2011. Other recommendation TBA

Louise Brown Rose Lance Christine Brisebois
N7 N4 N4
Phone 604-660-5865 604-660-3878 604-660-5843
_
s.15, s.22
/JI1V 12011
Date
S'tg' ture f Employer Representative
D te
Phone 604-660-5864 604-660-5864
the Human Resource Department. Keep Original and Forward Copy To: (1) Ministry Designate; (2) BCGEU Area Office; (3) Local OSH Committee; & (4) Local WCB office
JOINT INCIDENT INVESTIGATION FORM PSC38 Ministry Ministry of Children and Family Development Tel. # Location 3405 Willingdon Ave., Burnaby, B.C. First Name Occupation Date of Report 2011/04/06 File No. Hours Worked in Previous 24 Hour Period
604 660-5864

s.22
Years of Service
s.22
Time on Present Job
Child Care Counsellor

Incident Lo,cation (Dept. or Area) Crossroads Program I Incident Category (check)
Time
1830
0 Injury or Illness 0
0 Motor Vehicle
Severity of Injury or Illness (check) Nature of Injury or I"ness

s.22
I0
0 Property Damage
Fire
IZI Other
Threat/Assault Fatal *
Medical Treatment
0 Time Loss I0
reported "no injuries noted at time of incident".
Description of Incident or Employee's Account of

s.22
Disease (eg. RSI)

s.79 YCJA
Statement:
pushed me down onto the couch

s.79 YCJA s.79 YCJA
and broke the keys off the lanyard
hitting other staff
Were Written Safe Work Procedures Established and Available? Yes IZI No 0 N/A 0 Basic Cause (and Contributory Factors)
s.79 YCJA
IZI
No
N/A
Corrective Measures Taken and/or Recommended - No lanyards. to be used on complex - notice be sent to all staff - do not issue at time of hire
s.79 YCJA
Positioning of furniture should include a clear exit route Personal safety device Code policy for emergency circumstances If a circumstance arises where 1 staff will be alone staff need to make every effort to remove self from direct contact with youth Refresher of NVCI every 6 months
aSH meeting
Recommendations TBA
Name(s) & occupations of person(s) who investigated incident: Name Occupation Louise Brown N7 Rose Lance N4 Christine Broisebois N4
Phone 604-660-5865 604-660-3878 604-660-5843
? /Sfgnature of Workers' Representative
J1ktC;!
Dale
f /II

s.15, s.22
Phone 604-660-5864
JOINT INCIDENT INVESTIGATION FORM PSC 38 Ministry Tel. # Location Date of Report
604660-5864

First Name
2011/04/06
File No.

s.22
Years of Service
s.22
Time on Present Job
Occupation N4
7.5
Time
Crossroads Program
Date of Incident
2011/04/03
1830
IZI Other Assault
D Equipment
Malfunction
D No Injury or First Aid Only I D Medical Treatment
D Motor Vehicle
D Property D Fire
Damage
D Time Loss I 0
Fatal *
scratches to the Lt. forearm and upper lip, stiffness in s.22, s.79 YCJA neck and Lt. forearm as well as nose bleed from Lt. nostril.
Statement from
s.22 s.79 YCJA
keys. s.22, s.79 YCJA swings at both staff members. This resulted in scratches to in neck and Lt. forearm as well as nose bleed from Lt. nostril.
pushed her onto the couch grabbing several Lt. forearm and upper lip, stiffness s.22
Were Written Safe Work Procedures Established and Available? Yes IZI No D N/A D Basic Cause (and Contributory Factors)
N/A
Were these Safe Work Procedures used in Training? No N/A Yes IZI
s.79 YCJA
No lanyards to be used on complex - notice be sent to all staff - do not issue at time of hire
s.79 YCJA
Positioning of furniture should include a clear exit route Personal safety device Code policy for emergency circumstances If a circumstance arises where 1 staff will be alone staff need to make every effort to remove self from direct contact with youth Refresher of NVCI every 6 months
OSH meeting
Recommendations TBA
Louise Brown Rose Lance Christine Brisebois
N7 N4 N4
Phone 604-660-5865 604-660-3878 604-660-5843
!!pc;, 1/00J/(
/ Signature of Workers' Representative Date Name(s) of Witness(es) (include phone number): Name
s.15, s.22
Phone 604-660-5800
the Human Resource Department. Keep Original and Forward Copy To: (1) Ministry Designate; (2) BCGEU Area Office; (3) Local OSH Committee;

PSC38 Ministry Tel. # Location Date of Report
604660-5864
3405 Willingdon Ave, Burnaby, BC

First Name
March 28, 2011

File No.

s.22
Years of Service
s.22
Time on Present Job
Occupation
N4
8
Time
Crossroads Program
Date of Incident
March
2011
7:40 pm
Injury or Illness
0 Motor Vehicle
Severity of Injury or Illness (check) Nature of Injury or "Iness

s.22
I0
0 Property Damage
Fire
Other assault, theft, escaping legal custody
Medical Treatment
o Time Loss I D Fatal *
was assaulted
s.79 YCJA
Statement from
s.22
s.22, s.79 YCJA s.22 s.22 s.22 s.79 YCJA s.22 s.79 YCJA s.22 s.22
d at
s.22 s.22
s.79 YCJA
hit
s.22
s.79 YCJA s.79 YCJA s.22
in the left side of the head once with a closed fist. dug into her hand s.22
s.79 YCJA s.79 YCJA
s.22
s.79 YCJA
Were Written Safe Work Procedures Established and Available? Yes No 0 N/A 0
N/A
Were these Safe Work Procedures used in Training? NoO N/AO
Basic Cause (and Contributory Factors) - 2 staff

s.79 YCJA
rd

s.79 YCJA
.. 3 staff (Nurse) left unit to do drug count
Corrective Measures Taken and/or Recommended s.22 feels that CISO would be helpful. She has been given the number for the Employee Assistance Program.
feels that a button alarm system would have been helpful. s.22 .. Before leavinig unit staff need to assess stability of unit, youth and discuss with team members - If keys on neck they should be out of the sight of youth .. No lanyards that are not tear away - Other possible options for safety of keys ie. wrist lanyards however this could possibly result in back injuries .. Staff need to be reminded that their safety needs to be considered vs the immediate gratification of youth (smoke break) - Emergency ringers on other units not working and so delayed response to emergency calls
PC and aSH meetings
CISO completed Other recommendation TBA
Name(s) & occupations of person(s) who investigated incident: Name Occupation Giancarlo M. laertini 21 Rose lance N4 louise Brown N7 Program Coordinator
eec
Phone 604 660-5864 604 660-3878 604 660-5865
of Workers' Representative
Date
Sig a ure of Employer Representative
cOc24.3v
Date/

s.15, s.22
Phone 604 660-5864 604 660-5864

JOINT ACCIDENT INVESTIGATION FORM

PSC38 Ministry MCFD Tel. # 604-660-5865 Location 3405 Willingdon Ave., Burnaby, B.C. First Name Date of Report March 16, 2011 File No.
Last Name of Injured (or ill) Person

s.22
Years of Service
s.22
Time on Present Job

s.22
Occupation Childcare Counsellor
8
Date of Accident March 13, 2011 Time 2310 hrs.
Accident Location (Dept. or Area) Crossroads Program Accident Category (check) Injury or Illness
D Equipment D Motor
Malfunction Vehicle [&] No Injury or First Aid Only
D Property
Damage
D Fire
[&] Time Loss
[8] Other (specify)
D Medical
Treatment
D Fatal *
Nature of Injury or Illness s.22 was verbally threatened
s.79 YCJA
Description of Accident or Employee's Account of Occupational Disease (eg. RSI) (use separate sheet if necessary)
s.22
s.79 YCJA
s.22 s.22
s.22
Were Written Safe Work Procedures Established and Available? Yes[8] NoD N/AD
Were they Adequate? Yes[8] NoD N/AD
Were these Safe Work Procedures used in Training? Yes[&] NoD N/AD
Basic Cause (and Contributory Factors)
s.79 YCJA
Corrective Measures Taken and/or Recommended Staff debriefed event upon return to work with PC.
s.22 s.79 YCJA s.79 YCJA
s.22
_ _ _ _ __
Date To Be Completed By:__11C03/17_ __
Additional Comments or Observations. Where applicable give details of makes & models of machines, equipment, tools, structures, etc., involved in this accident. (Use separate sheet if necessary)
__ __
Phone Phone Date of Employer Representative Date
BRITISH COLUMBIA
Joint Incident Investigation Form,
The personal information requested on this form is collected under the authority of and will be used for the purpose of administering the Child, Family and Community Service Act (CFCS Act). Under certain circumstances, the collected information may be subject to disclosure as per the CFCS Act and/or the Freedom of Information and Protection of Privacy Act. Any questions about the collection, use or disclosure of this information should be discussed with the social worker involved with this agreement. TELEPHONE NUMBER LOCATION
I 604 660-5841
I'
YEARS OF SERVICE
MATC - 3405 Willingdon Ave., Burnaby, BC, V5G 3H4

FIRST NAME
LAST NAME OF INJURED (OR ILL) PERSON
s.22
TIME ON PRESENT JOB r0'-"C..;..C.;;.;UP..;..A..;..TI'-"O-'-'N_ _ _ _ _ _ _ _ _ _ _ _ _ _ _---, HOURS WORKED IN PREVIOUS 24-HOURS
s.22
II Child Care Counsellor
11 6
,'--0_ _ _ _ _ _ _ _ _ _ _ _ _ _----J112012-02-22
11 6 :45
CAM PM
IZllnjury or Illness DFire
D Motor Vehicle
D Property Damage
D Other
DTime Loss DFatal
D No Injury or First Aid Only IZl Medical Treatment

Worker stated that her shoulder and upper arm were sore and experienced some inmobility the following day.
Worker strained shoulder while participating in activity

WERE WRITTEN SAFE WORK PROCEDURES ESTABLISHED AND AVAILABLE? WERE THEY ADEQUATE?
s.79 YCJA
1
BASIC CAUSE (AND CONTRIBUTORY FACTORS)
YesONo
@ N/A
I0
WERE THESE SAFE WORK PROCEDURES USED IN TRAINING?
YesONo ,
N/A
Worker participatE?d in activity that is not a part of her normal daily activity. Did not warm up and used same arm motion in a repetitive
CORRECTIVE MEASURES TAKEN AND / OR RECOMMENDED
Advised worker to warm up/strech before physical activity. Advise worker to be aware of their physical fitness level and to respect their limitation,s.
CORRECTIVE ACTION REFERRED TO: TO BE COM PLED BY (YYYY-MM-DD)
Speak to employee about how to maintain her physica.l health before engaging in strl
ADDITIONAL COMMENTS OR OBSERVATIONS. WHERE APPLICABLE GIVE DETAILS OF MAKES AND MODELS OF MACHINES, EQUIPMENT, TOOLS, STRUCTURES, ETC. INVOLVED IN THIS INCIDENT. '
Name
Occupation
Phone
Bronwyn Armstrong Tracey Strain
Program Coordinator Child Care' Counsellor

DATE (YYYY-MM-DD) SIGNATURE OF EMPLOYER'S REPRESENTATIVE
604 660-5841 604660-5501

DATE (YYYY-MM-DD)
..... '-.....)-
CF0649_(11J03)
Page 1 of2
Name
NAME(S) OFWITNESS(ES).INCLUDE PHONE NUMBER:
Phone Phone
Name
N/A
Page 2 of2
BRITISH COLUMBIA
The personal information requested on this form is collected under the authority of and will be used for the purpose of administering the Child, Family and Community Service Act (CFCS Act). Under certain circumstances, the collected information may be subject to disclosure as per the CFCS Act and{or the Freedom of Information and Protection of Privacy Act. Any questions about the collection, use or disclosure of this information should be discussed with the social worker involved with this agreement.
I 604 660-5864
YEARS OF SERVICE
TELEPHONE NUMBER
LOCATION
MATC - Crossroads Program

FIRST NAME
I (ILENO.
s.22
s.22
IIL-_N_u_r_s_e________________.-......JII
I
11 3 :30
I 2012-02-09
AM (;' PM
[{]Injury or '"ness DFire
D Equipment Malfunction DOther
D Motor Vehicle
D Property Damage
[(] No Injury or First Aid Only D Medical Treatment

[ZJ Time Loss
Fatal
Scratch to R lower back and both forearms

s.79 YCJA
s.22
scratched on his R lower back and both forearms.

WERE THEY ADEQUATE?
(G Yes
No
N/A
(8 Yes
(' No
N/A
(G Yes
No
N/A
Proximity with Client during restraint

CORRECTIVE MEASURES TAKEN AND lOR RECOMMENDED
Offer more frequent NVCI refresher sessions for staff.

CORRECTIVE ACTION REFERRED TO:
I-1_O_S_H_c_om_m_it_te_e_,_p_ro_g_r_a_m_c_o_o_r_d_in_a_to_r_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
ADDITIONAL COMMENTS OR OBSERVATIONS.
-lll 2012-02-29
TO BE COM PLED BY (YYYY-MM-DD)
WHERE APPLICABLE GIVE DETAILS OF MAKES AND MODELS OF MACHINES, EQUIPMENT, TOOLS, STRUCTURES, ETC. INVOLVED IN THIS INCIDENT.
NAME(S) AND OC(UPATION(S) OF PERSON{S) WHO INVESTIGATED INCIDENT:
Name
Occupation
Phone
Dan Aitken Christine Brisebois
Program Coordinator Nurse

DATE (YYYY-MM-DD)
604660-5865 604660-5843
REPRESENTATIVE
DATE (YYYY-MM-DD)
.w{) IJdz/v
v"
REPRESENTATIVE
/\ I
Name
1_
2dt'26?ILc;
Phone
CF0649_(11/03)
Page 1 of 1
BRITISH COLUMBIA
The personal information requested on this form is collected under the authority of and will be used for the purpose of administering the Child, Family and Community Service Act (CFCS Act). Under certain circumstances, the collected information may be subject to disclosure as per the CFCS Act and/or the Freedom of Information and Protection of Privacy Act. Any questions about the collection, use or disclosure of this information should be discussed with the social worker involved with this agreement.
TELEPHONE NUMBER
I 604 660-5864
I MATC - Crossroads Program

FIRST NAME
LOCATION
(EpORT DATE
,VYYY-MM-OD)
FILE No.
L
YEARS OF SERVICE
s.22
TIME ON PRESENT JOB HOURS WORKED IN PREVIOUS 24-HOURS
s.22
II Nurse
II 8HRS
INCIDENT DATE (YYYY-MM-DD) .,.:.T.:.:.;IM:;,::E'--_--,
I
11 18:15
(. AM (8 PM
10
12012-02-27
I2J Injury or Illness

DFire
D Motor Vehicle
D Property Damage
I2J No Injury or First Aid Only
D Medical Treatment
DTime Loss
DFatal
I Staff's hair was pulled
s.79 YCJA
s.79 YCJA
Staff's neck and then
grabbed and pulled her hair.
WERE THEY ADEQUATE?
(e'
Yes C No
N/A
(e'
Yes
No
N/A
(e'
Yes
No
N/A
s.79 YCJA
staff to use techniques learned in NVCI. Add some refresher sessions of NVCI.
_____________________
NAME(S) AND O((UPATION(S) OF PERSON(S) WHO INVESTIGATED INCIDENT:
Name
Occupation
Phone
Dan Aitken Christine Brisebois
Program Coordinator
604 660-5865
/}
DATE 1!;<'({-'2,O/I
Nurse 4
604 660-5843
DATE (YYYY-MM-DD)
I/Z&3jg; I
Page 1 of2
CF0649_(11/03)
Name
I I
Phone Phone
Name
s.15, s.22
1604 660-5864
CF0649_(11/03)
Page 2 of2
BRITISH COLUMBIA
The personal information requested on this form is collected under the authority of and will be used for the purpose of administering the Child, Family and Community Service Act (CFCS Act). Under certain circumstances, the collected information may be subject to disclosure as per the CFCS Act andlor the Freedom of Information and Protection of Privacy Act. Any questions about the collection, use or disclosure of this information should be discussed with the social worker involved with this agreement.
I 604 660-5846 I I Maples Response Program

LAST NAME OF INJURED (OR ILL) PERSON FIRST NAME
TELEPHONE NUMBER
LOCATION
REPORT DATE (YYYY-MM-DD)
12012-03-26
FILE No.
L-
s.22
TIME ON PRESENT JOB
I <---I_
YEARS OF SERVICE
s.22
II Nurse
,. : O:. : C. : :,CU;:.:P. .:.,A:.:.;TI. : :,O:. ;.N_ _ _ _ _ _ _ _ _ _ _ _ _ _ _-,
II 0 HOURS
INCIDENT LOCATION (DEPARTMENT OR AREA
INCIDENT DATE (YYYY-MM-DD)
""T.;.;.;IM"",E,--_...,
C! 5'
[ljlnjury or Illness DFire
IS
0 :f-f'/c e
12012-03-26
11 12:20
CAM
(e') PM
DOther
D Motor Vehicle
D Property Damage
SEVERITY OF I NJURY OR ILLNESS (CHECK)
D No Injury or First Aid Only [lj Medical Treatment
DTime Loss
DFatal
I Bruising and pain to left jaw area.

s.79 YCJA s.79 YCJA
punched worker in the left jaw area.

WERE THEY ADEQUATE?
WERE WRITIEN SAFE WORK PROCEDURES ESTABLISHED AND AVAILABLE?
Yes C No
('i N/A
I r. Yes r
No
C N/A
Yes G No
N/A
s.79 YCJA
s.79 YCJA
s.79 YCJA
12012-03-26
Hallway outside of GP's office is surrounded by locked doors.

Name
Occupation
Phone
Bronwyn Armstrong Stephen Sjoberg

Program Coordinator/Shop Steward Program Coordinator ....
604 660-5841 604 660-5846

DATE (YYYY-MM-DD)
CF0649_(11/03)
Page 1 of2
BRITISH COLUMBIA
, Joint Incident Investigation Form
I
I. .
TELEPHONE NUMBER
000 000-0000
LOCATION
1 3405 Willindon Ave. Burnaby, B.C. V5G 3H4

FIRST NAME
12012-06-21
s.22
TIME ON PRESENT JOB r:o;.;:;C,;::..CU::.;.P..:..;AT.;.;.IO.;;;.;N"--_ _ _ _ _ _ _ _ _ _ _ _ _----,
YEARS OF SERVICE
s.22
_ II_Youth worker
__
II 8
10
12012-06-21
II
rT=IM.=..E_---,
5:45
AM
(it. PM
[Z] Injury or Illness

DFire
DOther
D Motor Vehicle
D Property Damage
[Z] Medical Treatment

s.22
[{]Time Loss
DFatal
s.79 YCJA stepped on resulted and hurts to move it. -s.22
foot
s.79 YCJA
Seen by unit nurse. Foot pain
s.79 YCJA
stepped on s.22 s.79 YCJA s.22 her foot. immediately yelled out and went to investigate her injures. A couple of hours later the pain had increased to the point where she felt it necessary to have a first aid attendant look at it.
I r.
WERE THEY ADEQUATE?
WERE THESE SAFE WORK PROCEDURES
Yes C No
(' N/A
I r.
Yes ('. No
N/A
N/A
Unsafe act by other -Unsafe Conditions due to inadequate footwear.

s.79 YCJA Worker changed foot wear to something more protective. Program Coordinator to follow up with Staff team to be made aware of need to be mindful of youth running on to to. to do set _. _ the
OH8 Committee, Program Coordinator, Program Manager
12012-07-21
Name
Michael, Short
Occupation
Phone
Iprogram Coordinator
1604 660-5846
CF0649_(11/03)
Page 1 of2
DATE (YYYY-MM-DD)
SIGNATURE OF EMPLOYER'S REPRESENTATIVE
12012-06-25 I
Name
Phone
s.22
1606 660-5843
CF0649_(11/03)
Page 2 of 2
BRITISH COLUMBIA
The personal information requested on this form is collected under the authority of and will be lIsed for the purpose of administering the Child, Family and Community Service Act (CFCS Act). Under certain circumstances, the collected information may be subject to disclosure as per the CFCS Act and/or the Freedom of Information and Protection of Privacy Act. Any questions about the collection, use or disclosure of this information should be discussed with the social worker involved with this agreement.
I
1,
TELEPHONE NUMBER
604 660-5846
I I Maples Response Unit

FIRST NAME
LOCATION
12012-05-29
I
I
s.22
I ('CE No.
HOURS WORKED IN PREVIOUS 24-HOURS INCIDENT DATE (YYYY-MM-DD) TIME
YEARS OF SERVICE
s.22
LI_C_h_ild_C_a_re_c_ou_n_s_e_1I0_r-=-._ _ _ _ _ _ _--l1/7.78
I 2012-05-25
11 9 :05
AM PM
[{] Injury or Illness DFire
D Motor Vehicle
D Property Damage
[{] No Injury or First Aid Only D Medical Treatment

DTime Loss
DFatal
Bruising and broken skin near right thumb.

s.22 s.22
s.79 YCJA s.79 YCJA
struck her on the right hand by the thumb, causing some scratching and bruising to the area around the thumb.
I rYes
s.22
WERE THEY ADEQUATE?
C No
N/A
(0
Yes
No
N/A
(0
Yes C No
C N/A
an inordinate amount of force.
CORRECTIVE MEASURES TAKEN AND I OR RECOMMENDED
s.22 s.79 YCJA
s.79 YCJA
'return' the I<eys in an unsafe manner.

TO BE COMPLED BY (YYYY-MM-DD)
______________________
NAME{S) AND OCCUPATION(S) OF PERSON{S) WHO INVESTIGATED INCIDENT:
Name
Occupation
Phone
Stephen Sjoberg Arth ur Bates

SP028 ((N 21
604 660-5846 604775-0462

DATE (YYYY-MM-DO)
12012-05-31
12012-05-30
Security Classification: PERSONAL
Page 1 of2
Name
I I
Phone
CF0649_(11/03)
Security Classification: PERSONAL
Page20f2
BRITISH COLUMBIA
The personal information requested on this form is collected under the authority of and will be used for the purpose of administering the Child, Family and Community SeNice Act (CFCS Act). Under certain circumstances, the collected information may be subject to disclosure as per the CFCS Act andlor the Freedom of Information and Protection of Privacy Act. Any questions about the collection, use or disclosure of this information should be discussed with the social worker involved with this agreement.
TELEPHONE NUMBER LOCATION REPORT DATE (YYYY-MM-DD)
I 604 660-5846
I Maples Response Program

FIRST NAME
I 2012-05-30
I
YEARS OF SERVICE
s.22
TIME ON PRESENT JOB
___________ 117.0
---'II .
I
CAM PM
FILE No
r:0;..;;C'-='C.;:;;UP'-'-A.;.:.T.:..;:IO:..:...;N'--_ _ _ _ _ _ _ _ _ _ _ _ _ _---,
s.22
II Child Care Counsel/or.
.-:T.:.;.:IM.;.=E'--_-,
10
12012-05-28
1113:00
[ZJ Injury or Illness

DFire
DOther
D Motor Vehicle
D Property Damage
[ZJ No Injury or First Aid Only

D Medical Treatment
DTime Loss
DFatal
s.22
twisted and strained her right ankle.

s.22
s.79 YCJA
was running across the sand and twisted her right ankle
WERE WRITIEN SAFE WORK PROCEDURES ESTABLISHED AND AVAILABLE?
WERE THEY ADEQUATE?
le. Yes C No
C, N/A
1 le' Yes
No
C N/A
Yes
No
n N/A
Poor, unsupportive footwear and an unstable surface.

s.22
has been informed of the job expectation that she wear required footwear while on the job.
_
ADDITIONAL COMMENTS OR OBSERVATIONS. WHERE APPLICABLE GIVE DETAILS OF MAKES AND MODELS OF MACHINES, EQUIPMENT, TOOLS, STRUCTURES, ETC. INVOLVED IN THIS INCIDENT
.1
lit is the employer's expectation that employees wear proper footwear while on the job.
Name
Occupation
Phone
Stephen Sjoberg Marzie De Pangher

S'G
SP028 CCN18
604660-5846 604660-5843
DATE (YYYY-MM-DD)
0
l/
OF
REPR'?i,-NTl
C2OF WITNESS(ES).INCLUDE ifJONE NUMBER:
12012-06-19
Name
I I I
1
Phone
..,
CF0649_(11/03)
Page 1 of 1
COLUMBIA
BRITISH
and Family Development.
The personal information requested on this form is collected under the authority of and will be used for the purpose of administering the Child, Family and Service Act (CFCS Act). Under certain circumstances, the collected information may be subject to disclosure as per the CFCS Act and/or the Freedom of InformatIon and Protection of Privacy Act. Any questions about the collection, use or disclosure of this information should be discussed with the social worker involved with this agreement.
TELEPHONE NUMBER LOCATION REPORT DATE (YYYY-MM-DD)
I...
..
. . . . .1
FIRST NAME
.... ...I
\2012-06-11 ...............................................................
FILE No
LAST NAME OF INJURED OR ILL PERSON
s.22
___
s.22
IN PREVIOUS '4-HOURS
I . . . . ... . .] I
INCIDENT DATE (VYYY-MM-DD)
2012-06-06
II
[Z]lnjury or Illness DFire
DOther
D Motor Vehicle
D Property Damage
D No Injury or First Aid Only

[Z] Medical Treatment
DTime Loss
DFatal
burn to staffs Right lower stomach area - s.22 refused medical treatment.
s.79 YCJA s.79 YCJA
covered staff's
a cup of coffee s.79 YCJA threw the contents of the cup at staff from about two feet away. the area below area down tohis waist.
WERE THEY ADEQUATE? WERE THESE SAFE WORK PROCEDURES
(!;. Yes
No
N/A
0 N/A
threw a hot cup of coffee at staff
s.79 YCJA
s.79 YCJA
TO BE COM PLED BY (VYYY-MM-DD)
s.79 YCJA
. f 2012-06-15
"" "" "
[" """Oil " "
uu,
= ""
OM"
uu"
== '"
=-
""""=""=""
tim
CUUU"UU
"
="=
==CUI
Name
Occupation
Phone
Dan Aitken
Program Coordinator
604 660-5865
CF0649_(11/03)
Page 1 of2

;--.
DATE (YVYY-MM-DD)
IJOl2huL2
,.
Name
Phone
s.15, s.22
604 660-5865
CF0649_(11/03)
Page 2 of2
COLUMBIA
BRITISH
The personal information requested on this form is collected under the authority of and will be used for the purpose of administering the Child, Family and Service Act (CFCS Act). Under certain circumstances, the collected information may be subject to disclosure as per the CFCS Act and/or the Freedom of InformatIOn and Protection of Privacy Act. Any questions about the collection, use or disclosure of this information should be discussed with the social worker involved with this agreement.
ITELEPHONE NUMBER]
LOCATION
.................................................................................
FIRST NAME
Crossroads Program
.......1
1..
...............
.
FILE No
. ?.. . . . . . . . . J
s.22
II:: .::.' ...:. .

I
(EARS OF SERVICE
e 1
ME
ON PRESENTJOB
1
..
..... .....
.... I=.1.0= .... = = = = = = = = == .. ..... ........
=lmll
IN PREVIOUS 24-HOUM
,.,;,T.;;;,;IM.;;;.,E_'"""""I
I
[l]lnjury or Illness DFire
o Equipment Malfunction
DOther
D Motor Vehicle
Property Damage
D No Injury or First Aid Only IZl Medical Treatment

[ZjTime Loss
DFatal
Bitten L thumb, neck/throat are as s.22 was choked. s.22 was also punched several times but not noted in
..
..
s.22 s.79 YCJA s.22
s.22 s.79 YCJA
...
hit him (throwing his fists at s.22 as you would swing a Hammer) s.22
s.22 s.22 s.79 YCJA s.22
s.22 s.79 YCJA s.22 s.22 s.22 s.22
s.22 s.22 s.79 YCJA
his Left thumb bitten s.22 s.22, s.79 YCJA

s.79 YCJA
WERE THEY ADEQUATE?
C N/A
BASIC CAUSE (AND CONTRIBUTORY FACTORS) EXPLAIN FULLY UNSAFE CONDITIONS
s.79 YCJA
s.79 YCJA
CORRECTIVE ACTION REFERRED TO: TO BE COMPLED BY (YYYY-MM-DD)
..
s.79 YCJA
... :. :.... :.... ]
CF0649_(11/03)
Page 1 of2
Name
Occupation
Phone
Dan Aitken Christine Brisebios

Program Coordinator Nurse

604 660-5865
DATE (WW-MM"O(
Name
Phone
CF0649_(11/03)
Page 2 of2
BRITISH COLUMBIA
I 604 660-5843 I I Maples Adolescent Treatment Centre

TELEPHONE NUMBER
LOCATION
12012-07-12
FILE No.
I
YEARS OF SERVICE
s.22
TIME ON PRESENT JOB
_____
---,IIL--_-'
I
la, PM
1 10
s.22
II Psychiatric Nurse
r:0:. .; :C. .; .C. : ;,;UP'-'-A.;.;. T;. ;:;IO-'-'N_ _ _ _ _ _ _ _ _ _ _ _ _ _ _.....,
118 HOURS
12012-06-01
D Equipment Malfunction DOther D Motor Vehicle
11 14:45
AM
[{] Injury or Illness DFire
D Property Damage

DTime Loss
DFatal
I Cut to nail bed of left index finger.

While slicing vegetables in the kitchen with a large kitchen knife, s.22 inadvertently cut down on the nail bed of her left index finger.
WERE THEY ADEQUATE?
(e'
Yes (' No
N/A
(e'
Yes (' No
N/A
(e'
Yes (' No
(' N/A
Carelessness. s.22 reports that: the knife that she was using was very sharp, there were no distractions and the cutting board surface was smooth and even.
Writer spoke to s.22 and she said that she will ensure that she is more focused when she is using sharp implements to prepare food.
CORRECTIVE ACTION REFERRED TO: TO BE COM PLED BY (YVYY-MM-DD)
s.22
who is going to use more caution when using sharps in the kitchen ora 12012-07-12.
NAME(S} AND OCCUPATION(S} OF PERSON(S} WHO INVESTIGATED INCIDENT:
Name
Occupation
Phone
Christine Brisebois Stephen Sjoberg(,l
Psychiatric Nursee SP028

DATE (YYYY-MM-DD) SIGNATURE OF EMPL0YER'S REPRESENTATIVE
604 660-5843 604660-5846

DATE (YYYY-MM-DD)
111.21
IOf, J I
Page 1 of2
Name
I I I
Phone Phone
Name
CF0649_(11/03)
Page 2 of2
COLUMBIA
BRrrIS:H
Ministry of Children and Fa.mily Development
The personal information requested on this form is collected under the authority of and will be used for the purpose of administering the Child, Family and Community SelVice Act (CFCS Act). Under certain circumstances, the collected information may be subject to disclosure as per the CFCS Act and/or the Freedom of Information and Protection of Plivacy Act. Any questions abollt the collection, use or disclosure ofthie information should be discussed with the social worker involved with this agreement. TELEPHONE NUMBER LOCATION REPORT DATE (YYYY-MM-DD)
.
1. .
s.22
Maples Adolescent Treatment Centre Burnaby

FIRST NAME
I.
s.22
N PRESENT JOB
I
1 7 .78
(ILENO.
I
I
o AM
PM
[l]lnjury or Illness DFire
DOther
D Motor Vehicle
D Property Damage
IZI No Injury or First Aid Only IZI Medical Treatment

DTime Loss
DFatal
Bruising and swelling to hand and forearm

During a 40 minute restraint
s.79 YCJA
WERE THEY ADEQUATE?
above injuries occurred

@Yes
No
C!
N/A
Yes
Ci
No
C)
N/A
Yes
No
C) N/A
BASICCAUSE-(AND CONTRIBUTORY FACTORS)
EXPLAIN FUL.L Y UNSAFE CONDITIONS
s.79 YCJA
No staff available to take over in a long restraint as on outings and one other unit closed.
Staff to be aware of staffing levels for safety

__
TO BE COM PLED BY (YYVY-MM-DD)
__
N/A
NAME(S} AND OCCUPATION(S) OF PERSON(S) WHO INVESTIGATED INCIDENT: Name Occupation Phone
Elisa Stewart
Acting Nurse 7
DATE (YYYY-MM-DD)
60,476,601,489
DATE (YYYY-MM-DD)
NAME(S} OF WITNESS(ES).INCLUDE PHONE NUMBER:
I
Name
},
"--""
y(,/j
12012-08-01
Phone
604660-3878
s.22
604660-3878 604660-5843
CF0649_(11/03)
Page 1 of 1
COIIJMBIA
BRrrrS:H
The personal information requested on tllis form is collected under the authority of and will be used for the purpose of administering the Chi/d, Family and Community SeJVice Act (CFCS Act). Under certain circumstances. the collected information may be subject to disclosure as per the CFCS Act and/or the Freedom of Information and Protection of Privacy Act. AllY questions about the collection, use or disclosure of this information should be discussed with the social worker involved with this agreement.
I
L
TELEPHONE NUMBER
LOCATION
REPORT DATE (YYVY-MM-DD)
Maples Adolescent Treatment Centre Burnaby

FIRST NAME
12.01
s.22
.1
(!lENO.
s.22
7 .78
TIME
I
D Motor Vehicle
DTime Loss
INCIDENT DATE (YYVY-MM-DD)
2012-07-31
11 18:30
C: AM
{'!) PM
12] Injury or Illness

DFire
DOther
D Property Damage
D No Injury or First Aid Only IZJ Medical Treatment

DFatal
Bite to right wrist with broken skin, Bruising and pain to both knees and elbows
During a 40 minute restraint
s.79 YCJA
WERE THEY ADEQUATE?
above injuries occurred
Yes 0 No
s.79 YCJA
0 N/A
(!) Yes
Cl No Ci N/A
I eEl
Yes 0 No
C, N/A
BASIC CAUSE (AND C.0NTRIBUTORY FACTORS)- - - - - - - - - - -- EXPLAIN FULLY UNSAFECONDITJONS - - - - - - -
- . --- -- .-.----
No staff available to take over in a long restraint as on outings and one other unit closed.
Staff to be aware of staffing levels for safety

_________________________ ADDITIONAL COMMENTS OR OBSERVATIONS. WHERE APPLICABLE GIVE DETAILS OF MAKES AND MODELS OF MACHINES, EQUIPMENT, TOOLS, STRUCTURES, ETC. INVOLVED IN THIS INCIDENT.
Name
Occupation
Phone
Elisa Stewart
Acting Nurse 7
60A76,601A89
_ DATE (YYVY-MM-DD)
DATE
-Name
MM DD)
SIGNATURE
NAME(S) OFWITNESS(ES).INCLUDE PHONE NUMBER:
"--"'"'" ""
/:r= ,
...
I
12012-08-01
Phone
604 660-3878
s.15, s.22
604660-3878 604660-5843
Security Classification: PUBLIC Page 1 of 1
BRITISH I Ministry of Children COLUMBIA and Family Development
The personal information requested on this form is collected under the authority of and will be used for the purpose of administering the Child, Family and Service Act (CFCS Act). Under certain circumstances, the collected information may be subject to disclosure as per the CFCS Act and/or the Freedom of InformatIon and Protection of Privacy Act. Any questions about the collection, use or disclosure of this information should be discussed with the social worker involved with this agreement.
I.
TELEPHONE NUMBER
LOCATION
..
. . . ..1
E
b[..
__ ____
s.22
___
FIRST NAME
__]
r.-. -. -------.. -..-.-. .-. -. .-.-.-. ""1.1 . . .. . . . . . . ..
s.22
PREBENT JOB
I(
..
...
.... r- .. C. .....
.... I-.Io...
WORKED IN PREVIOUB "HOURB

="""'")
I0
12012-08-26
Injury or Illness
11 7:30
D Motor Vehicle
Property Damage
DFire
Other
D Medical Treatment
._... - ........
DFatal
. . . . _..___.... . . . ._. ... _... _ . .. ...

s.79 YCJA s.22
WERE THEY ADEQUATE?
.. _.. _................... ........... .
......I
....
neck and forced her head to her knees when she was getting food out of the s.79 YCJA ...
'-
'(es
No
C! N/A
I ;
Yes
No
N/A
N/A
s.79 YCJA
cornered staff in the kitchen area
Contributory Factors: Staffing levels: ran with four staff as per usual, however on this day no male staff were on the unit.
.
s.79 YCJA
Staff need to always take the time to assess youth when interacting with them, never turn your back on the client. Staff to be mindful of clients mental health and unpredictability. Have the radio readily available use - why wasn't the radio used in this case?
s.79 YCJA
Staffing: ensure there are male staff to support the clinical needs of our male clients on the Crossroads unit.
s.79 YCJA
Page 1 of2
s.79 YCJA
'2012-08-301
ADDITIONAL COMMENTS OR OBSERVATIONS. WHERE APPLICABLE GIVE DETAILS OF MAKES AND MODELS OF MACHINES, EQUIPMENT, TOOLS, STRUCTURES, ETC. INVOLVED IN THIS INCIDENT. =" w==_= == - - = == -=
==---
Name
Occupation
Phone
Dan Aitken Marzie De Pang her

Program Coordinator Child Care Counsellor

it
604 660-5864
/J
/p
604 660-5843
DATE (YYYY-MM-DD)
Name
Phone
CF0649_(11/03)
Page 2 of2
BRITISH I Ministry of Children - . . - . COLUMBIA and Family Development
The personal information requested on this form is collected under the authority of and will be used for the purpose of administering the Child, Family and Community Service Act (CFCS Act). Under certain circumstances, the collected information may be subject to disclosure as per the CFCS Act andlor the Freedom of Information and Protection of Privacy Act. Any questions about the collection, use or disclosure of this information should be discussed with the social worker involved with this agreement.
ITELEPHONE NU MBER
.!
ME
LOCATION
3405 Willingdon Avenue Burnaby BC V5G 3H4

FIRST NAME
I2012-09-04
FILE No

.1
.........................................................
s.22
s.22
___
.....=.= = = = = = = = = = = . == = = =0.1.1 ... ... .........
r : ....:....:. . :]
ON PRESENT JOB 11=(=;c= ..
WORKED IN PREVIOUS 24-"OURS I

,..:.,T,;;;.;IM,;;:;.,E
INCIDENT DATE (YVYY-MM-DD)
I0 :
I (
11 18 :55
[lIlnjury or Illness DFire
DOther
D Motor Vehicle
D Property Damage
D No Injury or First Aid Only D Medical Treatment

NATURE OF INJ URY OR ILLNESS
[lITime Loss
DFatal
s.22
Right wrist was struck s.79 YCJA
s.79 YCJA
s.79 YCJA
formed a tight fist, raised

s.79 YCJA s.79 YCJA
his arm, and struck the shift head on her wrist.
WERE THEY ADEQUATE?
(!) Yes
No
N/A
Yes 0 ::
No
C)
N/A
NfA
Unsafe act of Client (basic cause) Contributory factors:
s.22, s.79 YCJA
CF0649_(11/03)
Page 1 of2
s.22, s.79 YCJA

s.79 YCJA
s.79 YCJA
I.
=". =
"=
=
["
==
===
-= = " "
"__
"= ==
======
===== === -" =====

Phone
==
==1
Name
Occupation
Dan Aitken
I
..
Program Coordinator
604660-5856
DATE (YYVY-MM-DDJ
..
DATE (YYYY-MM-DDJ
......
Name
Phone
CF0649_(11/03)
Page 2 of2
BRITISH COLUMBIA
The personal Information requested on this form is collected under the authority of and will be used for the purpose of administering the Child, Family and Community Service Act (CFCS Act). Under certain circumstances, the collected information may be subject to disclosure as per the CFCS Act andlor the Freedom of Information and Protection of Privacy Act. Any questions about the collection, use or disclosure of this information should be discussed with the social worker involved with this agreement.
I 604 660-5843 I I Maples Response program

TELEPHONE NUMBER
LOCATION
s.22
TIME ON PRESENT JOB
I IFILE No.
YEARS OF SERVICE
s.22
II Child Care Counsellor
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _....,
II 0
INCIDENT DATE (YYVY-MM-DD)
TIME
I 2012-09-17
1110:30
(8. AM (" PM
[Z] Injury or Illness

DFire
D Motor Vehicle
D Property Damage
[Z] No Injury or First Aid Only

D Medical Treatment
DTime Loss
DFatal
Twisted ankle, resulting in pain and swelling in the ankle area.

s.22 was walking toward the school on the grass beside the parking lot. was distracted by s.22 another colleague and inadvertantly stepped into an indent in the grass and rolled over her ankle (hyperextension). The indent was just between the curb and the grass and was about 2 ' long by 6" wide.
WERE THEY ADEQUATE?
(i
Yes
No
N/A
(i
Yes
No
N/A
1 (i Yes
No
(' N/A
Unsafe Condition: Uneven ground, covered in grass making it less easy to see. Personal Factor: Employee was distracted by another employee.
Response Program Coordinator will send a note to staff to ensure that they try to walk along the paved area of the parking lot as the grassy sections dividing it are quite uneven ..
__________________
Name
Occupation
Phone
Stephen Sjoberg Tracey Strain

SP028
604660-5846 604 603-8319

(((N 18
DATE (YYYY-MM-DD)
1 20 12-10-031
CF0649_(11/03) Security Classification: PUBLIC
12012-10-12
Page 1 of2
Name
NAME(S) OF WITNESS(ES). INCLUDE PHONE NUMBER:
Phone Phone
Name
CF0649_(11/03)
Page2of2
COLUMBIA
BRITISH
The personal information requested on this form is collected under the authority of and will be used for the purpose of administering the Child, Family and Community Service Act (CFCS Act). Under certain circumstances, the collected information may be subject to disclosure as per the CFCS Act and/or the Freedom of Information and Protection of Privacy Act. Any questions about the collection, use or disclosure of this information should be discussed with the social worker involved with this agreement. TELEPHONE NUMBER LOCATION REPORT DATE (YYYV-MM-DD)
I....
..
...... 1
Crossroads Program 3405 Willingdon. Avenue Burnaby BC.................. . . ........ ...... ............... ........... ............................... . .....
,
,-
[.. .
1
. . . . . . . . . . .I
I
FIRST NAME
1.
s.22
=
. . . . = = = = = =.. ..11 7 .78
===> .....
YEARS OF SERVICE
s.22
.............1
Injury or Illness
DOther
D Motor Vehicle
Property Damage
DFire
D Medical Treatment
s.22
DTime Loss
DFatal
s.79 YCJA s.22
striking them with her fists and kicking them.
s.22 s.79 YCJA s.79 YCJA s.22 s.22 s.79 YCJA s.22 s.22 s.79 YCJA s.22 s.22 s.22 s.22 s.22 s.79 YCJA s.22 s.22
area.
s.22
hit s.22 several times in her Right arm. s.79 YCJA was hit in the Right arm and shoulder strucks.79 YCJAin the head a couple of times. s.79 YCJA s.22
s.22 s.22
WERE THEY ADEQUATE?
p,i Yes
N/A
I (!) Yes
No
C' N/A
N/A
. . . . :.. . . . . . . . . . . . . . . . . . . . . . . .:.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .=..

.. . . . . . . . . . 1 .
s.79 YCJA s.79 YCJA
staff with long hair are now required to keep their hair up
(as opposed to hanging loosely).
I
CF0649_(11/03}
...................... ........... ......... .... . .............. ... . .
...................................................................................
BE COM PLED
Page 1 of2
Name
Occupation
Phone
Dan Aitken
.1604660-5865
DATE (YYYY-MM-DD)
DATE (YYYY-MM-DD)
Name
Phone
CF0649_(11/03)
Page 2 of2
BRITISH I Ministry of Children COLUMBIA and Family Development
mli' b=OC=A=T=IO=N====================.= =.== .... .... ..
= == = .... ..... .... ....
==>1
FILE No
..
.
I I
FIRST NAME
s.22
___
.. = . = = = = = = = = = = = = = == ,,-,-=,1 ... .... INCIDENT DATE
s.22
INCIDENT LOCATION (DEPARTMENT OR AREAl
IN PREVIOUS 24-HOURS I TIME
(mY-MMoo)
112012-09-23
IZIlnjury or Illness DFire
DOther
D Motor Vehicle
D Property Damage
[{] No Injury or First Aid Only

D Medical Treatment
DTime Loss
DFatal
s.79 YCJA s.22
pulling s.22
hair, punching and kicking her.

s.22 s.79 YCJA s.22
s.22
s.22
s.79 YCJA
to punch, kick, and pull female staffs hair.
s.79 YCJA
..
. t.<?
(!;. Yes Cj No
.. C)
N/A
s.22
s.79 YCJA . s.22
was kicking, and
..........................
No
WERE THEY ADEQUATE?
<!.\ Yes 0
C)
N/A
(!:: Yes
No
N/A
1?lient
s.79 YCJA
Nurses on Crossroads are to review their process of

s.79 YCJA
TO BE COMPLED BY (YYVY-MM-DD)
administering medication
Crossroads N5 will review their practice of administering medication
s.79 YCJA
(2012-09-28
ADDITIONAL COMMENTS OR OBSERVATIONS. WHERE APPLICABLE GIVE DETAILS OF MAKES AND MODELS OF MACHINES, EQUIPMENT, TOOLS, STRUCTURES, ETC. INVOLVED IN THIS INCIDENT. [ ."" a a aa" " "a au nL "" = = a= La " = = = = ==a -= = -== = = ==-- ==- =
NAME{S) AND OCCUPATION{S) OF PERSON{S) WHO INVESTIGATED INCIDENT: Name
Occupation
Phone
Dan Aitken
1604660-5865
CF0649_(11/03)
Page 1 of2
DATE (YYYY -MMDD)
(ATE ,YYVY-MMDD)
Name
Phone
I.
CF0649_(11/03)
Page2of2
COLUMBIA
BRITISH
The personal information requested on this form is collected under the authority of and will be used for the purpose of administering the Child, Family and Community Service Act (CFCS Act). Under certain circumstances, the collected information may be subject to disclosure as per the CFCS Act and/or the Freedom of Information and Protection of Privacy Act. Any questions about the collection, use or disclosure of this information should be discussed with the social worker involved with this agreement. TELEPHONE NUMBER LOCATION REPORT DATE (YYYY-MM-DD)
I.
. . . ..1
Crossroads Program 3405 Willingdon Avenue Burnaby BC

FIRST NAME
......... J
FILE No
s.22
...............
1
CA:Sa FSERVICEI
s.22
.... mm ........ m
.mmm ... m. .. ............mJ
. '.. . .
"HOURS I
...........
WORKED IN
,.;..T;;;,;IM;;;.,E
INCIDENT LOCATION (DEPARTMENT OR AREAl
2012-09-20 _ 1
1121 :40 . _
lOAM PM
Il] Injury or Illness

DFire
D Motor Vehicle
D Property Damage
Other
D Medical Treatment
s.22
DTime Loss
DFatal
s.79 YCJA s.22
striking them with her fists and kicking them.
s.22 s.79 YCJA s.79 YCJA s.22 s.22 s.79 YCJA s.22 s.79 YCJA s.22
s.22
area
s.22
s.22 s.22
hit s.22 several times in her Right arm. s.79 YCJA was hit in the Right arm and shoulder strucks.79 YCJA in the head a couple of times. s.79 YCJA s.22
s.79 YCJA s.22 s.22 s.22 s.22 s.22 s.22 in the head several times.
s.79 YCJA s.22
began striking
s.79 YCJA
I.:
L.?I
WERE THEY ADEQUATE?
C;
N/A
(,!; Yes
No
C:
N/A .. 1
0 N/AI
.................. ...................... ..................................
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .==. . . . . . . . .= ..
..........
..1
s.79 YCJA s.79 YCJA
staff with long hair are now required to keep their hair up
(as opposed to hanging loosely).
I
CF0649_(11/03)
.................................... .........m............ ............. ........ .......m....... ................... ..................................................
ITO BE COMPLED BY
Page 1 of2
Name
Occupation
Phone
Dan Aitken
Program Coordinator
604 660-5865
NAME(S) OF WITNESS(ES). INCLUDE PHONE NUMBER:
Name
Phone
CF0649_(11/03)
Page 2 of2
BRITISH COLUMBIA
The personal information requested on this form is collected under the authority of and will be used for the purpose of administering the Child, Family and Community Service Act (CFCS Act). Under certain circumstances, the collected information may be subject to disclosure as per the CFCS Act and/or the Freedom of Information and Protection of Privacy Act. Any questions about the collection, use or disclosure of this information should be discussed with the social worker involved with this agreement. TELEPHONE NUMBER
1 000 000-0000
II
LOCATION
3405 Willingdon ave

FIRST NAME
s.22
YEARS OF SERVICE TIME ON PRESENT JOB
_____________________
_ _ _ _ _ _ _ _ _ _ _ _ _ _ ____,
I .
FILE No
s.22
II
nurse
/17.78
I
assault DTime Loss
TIME
2012-09-25
11 9 :55
(ei'. AM
PM
o Injury or Illness
DFire
[Z] Other
D Motor Vehicle
Property Damage

o Fatal
I Soreness in right upper arm

s.22
was struck in the right upper arm

WERE THEY ADEQUATE?
s.79 YCJA
(8
Yes
No
N/A
I r.
Yes
No
N/A
rYes
No
r.
N/A
s.79 YCJA
s.79 YCJA Staff education around awareness of physical proximity more frequent self defence training could be offered by the employer.
Better and
__ c_o_m_m_i_tt_e_e__________________________________________________
______________
Phone
NAME(S) AND OC(UPATION(S) OF PERSON(S) WHO INVESTIGATED INCIDENT:
Name
Occupation
Jordan Griggs Marzie De Pangher
Shift supervisor child care counselor

DATE (YYYY-MM-DD) OF EMPLOYER'S REPRESENTATIVE
1
'i
604 660-5864 604660-5843

DATE (YYYY-MM-DD)
12012-09-27
Name
....
s.15, s.22
//J
12012-09-27
Page 1 of 1
COLUMBIA
BRITISH
aSH Joint Incident Investigation Form

PSC 38 Equivalent
This form must be initiated immediately after notification. This information is required by WorkSafeBC when serious workplace injuries and/or incidents occur that result in loss time (past the day of injury) or medical intervention. This report is also to be used for recording and investigating less serious incidents which include incidents with the potential to cause serious injury, violent incidents (threats, physical assault etc.) and IAQ complaints. Completed investigation reports must be kept at the worksite for a minimum of 7 years.
MCFD TRACKING NUMBER
INCIDENT LOCATION INFORMATION
I 604-660-5843
REPORTING OFFICE PHONE
DATE OF OCCURRENCE
DATE REPORTED
TIME OF INCIDENT
12012-10-02
12012-10-02
1
14:20
TO
1-1
42_1-----'P+
EXACT LOCATION OF INCIDENT (parking lot, meeting room etc)
3405 Willingdon Avenue

Pt;OPLE .INVOLVED
Willingdon & Goard Way intersection
NAME OF PERSON INCIDENT REPORTED TO
PHONE NUMBER (if different than reporting office)
1) Stephen Sjoberg
604-660-5846
NAME OF PERSON DIRECTLY AFFECTED
POSITION (e.g. Social Worker, Team Leader, Office Manager)
1)
s.22

POSITION (e.g. Social Worker, Team Leader, Office Manager) PHONE NUMBER (if different than reporting office)
604-660-5843
NAME OF WITNESS
INVOLVEMENT (e.g. what they saw, heard, their location at time of the incident, etc.)
____________________
1)1
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _L -_ _ _ _ _ _ _ _ _ _ _ _ _ _- L_ _ _ _ _ _ _ _ _ _ _ _
INCIDENT DETAIL INfORMATION

INCIDENT CATEGORY (CHECK ALL THAT APPLY)
ID Incidents
Violence Related
f{1 Environmental
I.Y.J Incidents
D Indoor Air Quality
(Le. scents, fumes, temperatures)
D Incidents
General
D Chemical Exposure
Biological D (Le. molds, fungi) Blood/Body Fluids D (Le. Needle Stick, contact with 88F)
D Substance
Spill/Release of Hazardous
Other
PLEASE SPECIFY
s.79 YCJA
SEVERITY OF INJURY OR ILLNESS (CHECK ALL THAT APPLY)
f{1 No PhysicallnJ'ury
I.Y.J
CF0649_(12/08)
D First Aid Only D (Dr. Clinic, Intervention Medical Ambulance)
r7I Time Loss I.Y.J (Not including day of injury) # of Days Loss:
D
Page 1 of3
Security Classification: MEDIUM SENSITIVITY
DFatal
TYPE OF INJURY OR ILLNESS (CHECK ALL THAT APPLY)
Knocks, Scrapes, D Musclerrendon D Abrasions, Bruises Strains Musclerrendon D Fractures D Tears DOther
BODY PART(S) INJURIED OR AFFECTED (CHECK ALL THAT APPLY)
DSprains D Lacerations/Cuts
Medical Sensitivity D (scents, chemicals) D Disease
'71 Post Traumatic

Stress D Burns
Upper
D Mid Body arms) D Lower Body (including

(Le. lighting, sound, chemical exposure)
PHYSICAL SURROUNDINGS DETAILS (IF APPLICABLE)
Object/Equipment/Substance inflicting injury ordama e
Environmental Conditions at time of incident
N/A
. :1
Dry and clear in mid-day
, DESCRIPTION OF INCiDEN'T
Who, What, Where, When, Why - Employee's Account (be specific as possible with worker'S names, times, locations and use initials for client names)
s.22 s.79 YCJA
oncoming bus and s.22 had to physically step in to the lane while waving her arms to alert the,bus driver who saw her and s.79 YCJA and stopped just in front of them. 'ANALYSIS
Immediate Basic Cause(s)
(What triggered the incident - i.e. fall from height, caught in machinery, child removal etc.)
1)
s.79 YCJA
Underlying Cause and Contributing Factors
(What allowed the condition to exist - i.e. inadequate training, lack of written work procedures; worker not being monitored; poor lighting; defective equipment; working alone, no orientation, noise etc.) a)
s.79 YCJA
b)
ADDITIONAL COMMENTS OR OBSERVATIONS Where applicable, give details of other hazards, which mayor may not be related to the incident.
In future, Response staff are going to ensure that clients from small towns have a chance to orient themselves to the busy roadways in the lower mainland. This can be done by front loading and then escorting the youth to the corner of Canada Way and Willingdon (the busiest intersection in BC) to watch the traffic and observe how pedestrians safely navigate their way across Canada Way and/or Willingdon Avenue. OSH COMNUTEE JOINT INVESTIGAtORS
NAME(S) AND OCCUPATION(S) OF PERSON(S) WHO INVESTIGATED INQQ5tlT:
Name
t7 4'
Occupation
Phone
r.:.
//
SP028 CeNi8
604660- 58
i1
//
604 603-831j
CF0649_(12/08)
Page 2 of3
OSH Joint Incident Investigation Form

PSC 38 Equivalent

REPORTING OFFICE PHONE DATE OF OCCURRENCE DATE REPORTED TIME OF INCIDENT
604-660-5841
ADDRESS OF INCIDENT (street address, city/town)
2012-12-26
2012-12-27 Crossroads Unit hallway
1830
PM
TO
1,845
3405 Willingdon Avenue, Burnaby BC PEOPLE INVOLVED
1) Alison Bergum 2) Christine Brisebois 3) Michelle Warry 4) Jody Al-molky
604-660-5843 604-660-5857 604-660-5815

1)
s.22

604-660-5864
NAME OF WITNESS
1)
s.15, s.22
Nurse
604-660-5800
2)
Nurse
Witnessed event through the glass of the Staff office. Participated in restraint. Overheard interaction through nursing office. Participated in restraint of client.
INCIDENT DETAIL INFORMATION

CF0649_(12/08)
Phase 1 PagePage 1 of 4 77 CFD-2013-00082
Violence Related Incidents
Verbal Threat
(i.e. abusive swearing, physical harm, veiled or perceived)
Environmental Incidents
General Incidents
Written Threat
Bomb Threat
(i.e. written, verbal)
Weapon Threat Intimidating Behaviour

(i.e. stalking, infringement on physical space)
Aggressive Behaviour
(slamming fist, kicking door, damaged property)
Physical Assault
(i.e. physical injury)
Animal Related
(i.e. attacked, menacing behaviour)
Vehicular Assault Worker to Worker

(i.e. actual or perceived threats, intimidation)
Other
No Physical Injury Knocks, Scrapes, Abrasions, Bruises Muscle/Tendon Tears Other
First Aid Only Muscle/Tendon Strains Fractures
Medical Intervention
(Dr. Clinic, Ambulance)
Time Loss
(Not including day of injury)
Fatal Post Traumatic Stress Burns
Sprains Lacerations/Cuts
Medical Sensitivity
(scents, chemicals)
Disease
Upper Mid Body (including arms)
Head
Ear
Eyes
Neck
Lower Body
Object/Equipment/Substance inflicting injury or damage
(i.e. lighting, sound, chemical exposure)
Office Structures implicated in incident (i.e doors)
CF0649_(12/08)
DESCRIPTION OF INCIDENT
Who, What, Where, When, Why - Employee's Account (be specific as possible with worker's names, times, locations and use initials for client names)
s.79 YCJA s.22 s.22 s.22 s.22 s.79 YCJA
s.22 s.22
stated Im going to choke you till youre blue. neck and tried to pull s.22 towards her s.22
s.79 YCJA
s.22 s.22
grabbed
s.22
around the neck and grab his head and fell to the ground.
ANALYSIS
Return to Basic Causes
1) Immediate Basic Cause:

Causes include the aggressive / assaultive acts of the youth, possible contagion factor of other youth who was activated.
Recommended Control, Corrective Measures or Treatment Provided
(goal is to prevent/minimize re-occurrence of accident/incident) A)
Actioned by
Completion Date
2013-01-04
Staff directed to maintain safe physical distances, increasing distance to decrease potential physical harm. s.79 YCJA
s.79 YCJA Employer's Response to Recommendation
Implemented in Workplace
Alison Bergum
Yes
No
Comments
B)
Query whether current Progressive Intervention training includes hold releases and defensive stances. Alison to follow up with PI training coordinator. Ensure all staff have current and up to date training and opportunities to practice are made regularly by shiftheads. Plan to discuss with standing unit program coordinator upon return.
Employer's Response to Recommendation
Alison Bergum
2013-01-11
Yes
No
Comments
C)
Where appropriate or indicated the separation of aggressor from other, activated youth, proactively as a means of avoiding or reducing agitation by mirroring others. This includes the use of current designated resource of unoccupied unit.
Alison Bergum
2013-01-03
Yes
No
Comments
ADDITIONAL COMMENTS OR OBSERVATIONS Where applicable, give details of other hazards, which may or may not be related to the incident.
Name
Signature
Occupation
Phone
CF0649_(12/08)
OSH COMMITEE JOINT INVESTIGATORS

Name Signature Occupation Phone
Alison Bergum Arthur Bates
Program Coordinator SPO
604 660-5841 604 775-0462
Keep Original and Forward a copy of the interim report to: (1) Local JOSH Committee co-chairs for committee discussion and further recommendations. Keep Original and Forward a copy of the completed report to: (1) Employer for their review and action; (2) BCGEU Area Office (3) Regional MCFD OSH Advisor (4) Local WorkSafeBC Office if requested. Further assistance can be obtained by contacting your Regional OSH Advisor or the BCGEU. This form is considered confidential once it has been completed. If you have received a completed form in error please forward it to your Regional OSH Advisor and destroy/permanently delete your copy.
SIGNATURE OF WORKER'S REPRESENTATIVE DATE (YYYY-MM-DD) SIGNATURE OF EMPLOYER'S REPRESENTATIVE DATE (YYYY-MM-DD)
CF0649_(12/08)

PSC 38 Equivalent

604-660-5800
2012-12-28
2012-12-28
1645
PM
TO
1,717
PM
3405 Willingdon Ave. Burnaby, BC PEOPLE INVOLVED
Crossroads Unit: Staff Office
1) Alison Bergum 2) Elisa Stewart 3) Jody Al-molky
604-660-5841 604-660-3878 604-660-5815

1)
s.22
Nurse
POSITION (e.g. Social Worker, Team Leader, Office Manager) PHONE NUMBER (if different than reporting office) INVOLVEMENT (e.g. what they saw, heard, their location at time of the incident, etc.)
NAME OF WITNESS
1) 2) 3)
Nurse Shift Supervisor Child Care Counsello
Provided First Aid treatment Responded to incident, involved in restraint Witnessed assault, responded and involved in restraint. Witnessed assault, responded and involved in restraint. Witnessed assault, responded and involved in restraint. Working on shift at the time. Did not witness assault as off unit supervising another youth.
4)
s.15, s.22
Child Care Counsello
5)
6)

CF0649_(12/08)
Verbal Threat
General Incidents
Written Threat
Bomb Threat

Physical Assault
Animal Related

Other
No Physical Injury Fatal
First Aid Only
Time Loss
# of Days Loss: 4
Knocks, Scrapes, Abrasions, Bruises Muscle/Tendon Tears Other
Muscle/Tendon Strains Fractures
Medical Sensitivity
(scents, chemicals)
Post Traumatic Stress Burns
Disease
Head Right Shoulder Left Shoulder Upper Back
Ear Right Arm Left Arm Mid Back
Eyes Right Elbow Left Elbow Lower Back
Neck Right Wrist Left Wrist Right Hand/Fingers Left Hand/Fingers
Lower Body
CF0649_(12/08)
s.79 YCJA
s.22
s.22
turned and began punching s.22 numerous times in the head. s.22 put her arms up to cover her face and head in a defensive move YCJA made contact with s.22 left and right arm and hand s.79 s.79 YCJA
s.22 s.22 s.22 s.79 YCJA
ANALYSIS

Aggressive Act of Client
Actioned by
Completion Date
2013-01-11

Implemented in Workplace B)
Dan Aitken
Yes
No
Comments
Recognition of early signs of aggression and taking steps to remove specific staff if being targeted.
Shift Supervisors
2013-01-11
Yes
No
Comments
C)

Implemented in Workplace D)
Everyone
2013-01-31
Yes
No s.79 YCJA
Comments
Clinical Team
Comments
2013-01-18

Implemented in Workplace E)
Yes
No
Employer to review staffing needs including taking steps to reduce overtime (ie. increasing auxiliary staff list).
Management Team
2013-01-31
Yes
No
Comments
JOSH investigators wished to interview all parties involved however proceeded with investigation without doing so due to staff being off / unavailable and to ensure a timely process.
Name
Signature
Occupation
Phone
Alison Bergum
Program Coordinator
604 660-5841
CF0649_(12/08)

Name Signature Occupation Phone
Arthur Bates Christine Brisebois
SPO Nurse
604 775-0462 604 660-5843
CF0649_(12/08)

PSC 38 Equivalent

604-660-5800
2012-12-28
2012-12-28 Crossroads Unit Hallway
1000
AM
TO
1,030
AM
3405 Willingdon Ave, Burnaby BC PEOPLE INVOLVED
1) Alison Bergum
1)
s.22
Shift Supervisor: Child Care Coun

POSITION (e.g. Social Worker, Team Leader, Office Manager) PHONE NUMBER (if different than reporting office) INVOLVEMENT (e.g. what they saw, heard, their location at time of the incident, etc.)
NAME OF WITNESS
1) 2)
s.15, s.22
Child Care Counsello Child Care Counsello Child Care Counsello Nurse
Involved in the interaction and restraint. Involved in the restraint. Involved in the restraint. Witness.
3) 4)

CF0649_(12/08)
Verbal Threat
General Incidents
Written Threat
Bomb Threat

Physical Assault
Animal Related

Other
No Physical Injury Knocks, Scrapes, Abrasions, Bruises Muscle/Tendon Tears Other
First Aid Only Muscle/Tendon Strains Fractures

PLEASE SPECIFY
Time Loss
Fatal Post Traumatic Stress Burns
Medical Sensitivity
(scents, chemicals)
Disease
Swelling and reddened area to right knee, soft tissue area.

Mid Body (including arms)
Buttocks Right Leg Left Leg Hip Right Knee Left Knee Right Foot/Toes/Heel Left Foot/Toes/Heel
Upper Lower Body
CF0649_(12/08)
s.79 YCJA
s.22
landed heavily on his right knee. Initially deferred nursing assessment however later accepted ice and had nursing assessment. ANALYSIS

Aggression and escalating agitation of youth initiated the need for a restraint.
Actioned by
Completion Date
2013-01-11

Implemented in Workplace B)
Alison Bergum
Yes
No
Comments s.79 YCJA
Ensure appropriate pass over of information

s.79 YCJA
Plan to discuss and review communication methods with standing program coordinator upon his return.
Implemented in Workplace C)
Alison Bergum
2013-01-11
Yes
No
Comments
Review of staffing practice during holiday periods including the clinical team. Identify need for consistency in order to follow primary model. Plan to recommend greater consistency of regular staff during critical periods at Program Operations Committee.
Alison Bergum
2013-01-23
Yes
No
Comments
Have OSH committee to review presence of police weapons on the unit / any previous policy around same. OSH COMMITEE JOINT INVESTIGATORS
Name
Signature
Occupation
Phone
Alison Bergum Arthur Bates
Program Coordinator SPO
604 660-5841 604 775-0462
CF0649_(12/08)
CF0649_(12/08)

PSC 38 Equivalent

604 660-5846
2012-12-28
2012-12-28
17:30
PM
TO
1,750
PM
3405 Willingdon Avenue PEOPLE INVOLVED
Crossroads' staff lounge (bubble room)
1) Elisa Stewart 2) Alison Bergum
604-660-1489 604-660-5841
1)
s.22

604-660-5843
NAME OF WITNESS
1) 2)
s.15, s.22
Child Care Counselo 604-660-5864 Child Care Counselo 604-660-3878 Child Care Counselo 604-660-3878 Child Care Counselo 604-660-5864
3) 4)
Was part of restraint that led s.22 to injuries Was part of restraint that led s.22 to injuries Was part of restraint that led s.22 to injuries Was part of restraint that led to injuries s.22

CF0649_(12/08)
Verbal Threat
General Incidents
Written Threat
Bomb Threat

Physical Assault
Animal Related

Other
No Physical Injury Fatal
First Aid Only
Time Loss
# of Days Loss:
Knocks, Scrapes, Abrasions, Bruises Muscle/Tendon Tears Other
Muscle/Tendon Strains Fractures
Medical Sensitivity
(scents, chemicals)
Post Traumatic Stress Burns
Disease

Right Shoulder Left Shoulder Upper Back Right Arm Left Arm Mid Back Hip Right Knee Left Knee Right Foot/Toes/Heel Left Foot/Toes/Heel Right Elbow Left Elbow Lower Back Right Wrist Left Wrist Right Hand/Fingers Left Hand/Fingers
Lower Body
Buttocks Right Leg Left Leg
Abrasions from carpet below youth's legs that were being held during the restraint.
Well lit office space that was cramped
Chairs and desks in the office
CF0649_(12/08)
s.22 s.22 s.22 s.22 s.79 YCJA s.22
sustained bruising to the side of her left leg and ankle and a small cut on top of her right wrist. ANALYSIS

Youth was in a highly agitated state, after being restrained earlier in the shift and seemed unable to bring fdown her affective response. Youth wound up lunging at a staff in the staff office and started punching her in the head necessitating her restraint.
Actioned by
Completion Date
s.79 YCJA
1) Dan Aitken/Jody Al-Molky/ Tom Jensen/Crossroads' Shift Supervisors (in-progress) 2) Stephen Sjoberg - NVCI trainer who will ensure that shift supervisors are reviewing NVCI techniques with their staff. (in-progress) 3) Crossroads clinical team (inprogress)
2) Review restraint techniques with staff and incorporate them into in-service sessions during slow periods in a shift.
Current for all
s.79 YCJA

Yes
No
Comments

Name
Signature
Occupation
Phone
SPO 28 CCN 18
604 660-5843 604 603-8319
2013-01-09
CF0649_(12/08)

PSC38 Forms For The Maples Adolescent Treatment Centre

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Judul Asli

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PSC38 Forms For The Maples Adolescent Treatment Centre

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Obtained by Bob Mackin via Freedom of Information 2010goldrush@gmail.com twitter.

Last name of Injured (or ill) Person Years of Service

Time on Present Job

Incident Location (Dept. or Area) Crossroads

Date of Incident November 1, 2010

Incident Category Jcheck)

Severity of Injury or Illness -<cheek)

[gI No Injury or First Aid Only

Description of Incident or Employee's Account of Occupational Disease (eg. RSI)

Were they Adequate? Yes [gI No

Were these Safe Work Procedures used in Training? NoD N/AO

EXPLAIN FULLY UNSAFE CONDITIONS

Phase 1 Page 1 CFD-2013-00082

Corrective Measures Taken and/or Recommended

Corrective Action Referred To:

Date To Be Completed By:

Name(s) & occupations of person(s) who investigated incident: Name Occupation

Phone 604-660-5864 604-775-0462

Phase 1 Page 2 CFD-2013-00082

Last name of Injured (or ill) Person

Time on Present Job

Date of Incident September 2010

Severity of Injury or Illness (check)

No Injury or First Aid Only

Other Time Loss

Were they Adequate? NoD N/AO

Were these Safe Work Procedures used in Training? YesO NoD

EXPLAIN FULLY UNSAFE CONDITIONS

Phase 1 Page 3 CFD-2013-00082

Corrective Action Referred To:

Date To Be Completed By:

Signature of Workers' Representative

Signature of Employer Representative

Name{s) ofWitness{es) (include phone number): Name

Phase 1 Page 4 CFD-2013-00082

JOINT INCIDENT INVESTIGATION FORM

Ministry of Children and Family Development

Maples Response Unit

July 22, 2010

Last name of Injured (or ill) Person

Time on Present Job

Hours Worked in Previous 24 Hour Period

Child Care Counselor

Incident Location (Dept. or Area)

July 15, 2010

Severity of Injury or Illness (check) Nature of Injury or Illness

IZI No Injury or First Aid Only

Sprained right knee.

Description of Incident or Employee's Account of Occupational Disease (eg. RSI)

Were they Adequate? Yes

EXPLAIN FULLY UNSAFE CONDITIONS

Stop/start movement on a sticky floor.

Phase 1 Page 5 CFD-2013-00082

Corrective Measures Taken and/or Recommended

Corrective Action Referred To:

Date To Be Completed By:

Name(s) & occupations of person(s) who investigated incident: Name Occupation

Dan Luoma Stephen Sjoberg

Child Care Counselor Social Program Officer

Phone (604) 660-5864 (604) 660-5846

Name( s) of Witness( es) (include phone number): Name

Phase 1 Page 6 CFD-2013-00082

Ministry of Children and Family Development