| PGPL

2021 Risk Assessment Survey

The purpose of this survey is to help your Health & Safety Committee to complete an organization-wide Risk Assessment. The Risk Assessment is required by WorkSafeBC and is for risks that impact staff in their work, not risks to the public. The goal is to identify hazards that impact staff health and safety, determine their level of risk, and develop strategies to reduce the risks identified.

Personal Information

Workplace Location *

Name *

Email *

Workplace Hazards

Identify and describe the hazards you face in your workplace on a daily basis. A hazard is defined as anything you encounter in the course of your work that can harm or adversely affect you.

Hazard #1

Hazard:

Hazard #1 *

Hazard Description *

Hazard Category *

Other Category:

Other Category *

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): *	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level *

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members: *	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings *

Hazard #2

Hazard:

Hazard #2 *

Hazard Description

Hazard Category

Other Category:

Other Category

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern):	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members:	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings

Hazard #3

Hazard:

Hazard #3

Hazard Description

Hazard Category

Other Category:

Other Category

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern):	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members:	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings

Hazard #4

Hazard:

Hazard #4

Hazard Description

Hazard Category

Other Category:

Other Category

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern):	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members:	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings

Hazard #5

Hazard:

Hazard #5

Hazard Description

Hazard Category

Other Category:

Other Category

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern):	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members:	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings

Add Another Hazard?

Hazard #6

Name of Hazard:

Name of Hazard *

Hazard Description *

Hazard Category *

Other Category:

Other Category *

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): *	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level *

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members: *	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings *

Add Another Hazard? *

Hazard #7

Name of Hazard:

Name of Hazard *

Hazard Description *

Hazard Category *

Other Category:

Other Category *

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): *	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level *

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members: *	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings *

Add Another Hazard? *

Hazard #8

Name of Hazard:

Name of Hazard *

Hazard Description *

Hazard Category *

Other Category:

Other Category *

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): *	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level *

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members: *	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings *

Add Another Hazard? *

Hazard #9

Name of Hazard:

Name of Hazard *

Hazard Description *

Hazard Category *

Other Category:

Other Category *

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): *	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level *

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members: *	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings *

Add Another Hazard? *

Hazard #16

Name of Hazard:

Name of Hazard *

Hazard Description *

Hazard Category *

Other Category:

Other Category *

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): *	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level *

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members: *	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings *

Add Another Hazard? *

Hazard #19

Name of Hazard:

Name of Hazard *

Hazard Description *

Hazard Category *

Other Category:

Other Category *

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): *	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level *

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members: *	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings *

Add Another Hazard? *

Hazard #18

Name of Hazard:

Name of Hazard *

Hazard Description *

Hazard Category *

Other Category:

Other Category *

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): *	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level *

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members: *	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings *

Add Another Hazard? *

Hazard #17

Name of Hazard:

Name of Hazard *

Hazard Description *

Hazard Category *

Other Category:

Other Category *

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): *	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level *

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members: *	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings *

Add Another Hazard? *

Hazard #11

Name of Hazard:

Name of Hazard *

Hazard Description *

Hazard Category *

Other Category:

Other Category *

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): *	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level *

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members: *	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings *

Add Another Hazard? *

Hazard #15

Name of Hazard:

Name of Hazard *

Hazard Description *

Hazard Category *

Other Category:

Other Category *

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): *	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level *

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members: *	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings *

Add Another Hazard? *

Hazard #14

Name of Hazard:

Name of Hazard *

Hazard Description *

Hazard Category *

Other Category:

Other Category *

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): *	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level *

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members: *	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings *

Add Another Hazard? *

Hazard #13

Name of Hazard:

Name of Hazard *

Hazard Description *

Hazard Category *

Other Category:

Other Category *

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): *	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level *

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members: *	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings *

Add Another Hazard? *

Hazard #12

Name of Hazard:

Name of Hazard *

Hazard Description *

Hazard Category *

Other Category:

Other Category *

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): *	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level *

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members: *	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings *

Add Another Hazard? *

Hazard #10

Name of Hazard:

Name of Hazard *

Hazard Description *

Hazard Category *

Other Category:

Other Category *

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): *	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level *

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members: *	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings *

Add Another Hazard? *

Hazard #20

Name of Hazard:

Name of Hazard *

Hazard Description *

Hazard Category *

Other Category:

Other Category *

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): *	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level *

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members: *	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings *

What changes to the workplace would reduce or eliminate risks of injury/violence to staff? (optional)

Leave this field blank

Read more about 2021 Risk Assessment Survey

Reference Follow-Up Form

Patron Info

Name *

Library Card Number

Email

Phone

Preferred Contact Method *

Date/Time of Question Submission

Date *

Month

Day

Year

Time *

Hour

:

Minute

am

pm

Question Details

Staff Member (Original Interaction) *

Reference Interview Description *

Notes

Leave this field blank

Read more about Reference Follow-Up Form

COVID-19 Risk Assessment for Library Programs/Services

Risk evaluation when deciding whether to postpone/cancel a mass gathering of people at the library

Read more about COVID-19 Risk Assessment for Library Programs/Services

2019 Risk Assessment Survey

The purpose of this survey is to help your Health & Safety Committee to complete an organization-wide Risk Assessment. The Risk Assessment is required by WorkSafeBC and is for risks that impact staff in their work, not risks to the public. The goal is to identify hazards that impact staff health and safety, determine their level of risk, and develop strategies to reduce the risks identified.

Personal Information

Workplace Location *

Name *

Email *

Workplace Hazards

Identify and describe the hazards you face in your workplace on a daily basis. A hazard is defined as anything you encounter in the course of your work that can harm or adversely affect you.

Hazard #1

Name of Hazard:

Name of Hazard *

Hazard Description *

Hazard Category *

Other Category:

Other Category *

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): *	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level *

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members: *	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings *

Hazard #2

Name of Hazard:

Name of Hazard *

Hazard Description

Hazard Category

Other Category:

Other Category

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern):	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members:	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings

Hazard #3

Name of Hazard:

Name of Hazard

Hazard Description

Hazard Category

Other Category:

Other Category

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern):	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members:	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings

Hazard #4

Name of Hazard:

Name of Hazard

Hazard Description

Hazard Category

Other Category:

Other Category

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern):	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members:	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings

Hazard #5

Name of Hazard:

Name of Hazard

Hazard Description

Hazard Category

Other Category:

Other Category

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern):	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members:	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings

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Hazard #6

Name of Hazard:

Name of Hazard *

Hazard Description *

Hazard Category *

Other Category:

Other Category *

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): *	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level *

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members: *	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings *

Add Another Hazard? *

Hazard #7

Name of Hazard:

Name of Hazard *

Hazard Description *

Hazard Category *

Other Category:

Other Category *

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): *	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level *

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members: *	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings *

Add Another Hazard? *

Hazard #8

Name of Hazard:

Name of Hazard *

Hazard Description *

Hazard Category *

Other Category:

Other Category *

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): *	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level *

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members: *	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings *

Add Another Hazard? *

Hazard #9

Name of Hazard:

Name of Hazard *

Hazard Description *

Hazard Category *

Other Category:

Other Category *

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): *	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level *

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members: *	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings *

Add Another Hazard? *

Hazard #16

Name of Hazard:

Name of Hazard *

Hazard Description *

Hazard Category *

Other Category:

Other Category *

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): *	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level *

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members: *	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings *

Add Another Hazard? *

Hazard #19

Name of Hazard:

Name of Hazard *

Hazard Description *

Hazard Category *

Other Category:

Other Category *

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): *	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level *

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members: *	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings *

Add Another Hazard? *

Hazard #18

Name of Hazard:

Name of Hazard *

Hazard Description *

Hazard Category *

Other Category:

Other Category *

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): *	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level *

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members: *	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings *

Add Another Hazard? *

Hazard #17

Name of Hazard:

Name of Hazard *

Hazard Description *

Hazard Category *

Other Category:

Other Category *

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): *	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level *

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members: *	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings *

Add Another Hazard? *

Hazard #11

Name of Hazard:

Name of Hazard *

Hazard Description *

Hazard Category *

Other Category:

Other Category *

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): *	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level *

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members: *	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings *

Add Another Hazard? *

Hazard #15

Name of Hazard:

Name of Hazard *

Hazard Description *

Hazard Category *

Other Category:

Other Category *

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): *	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level *

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members: *	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings *

Add Another Hazard? *

Hazard #14

Name of Hazard:

Name of Hazard *

Hazard Description *

Hazard Category *

Other Category:

Other Category *

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): *	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level *

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members: *	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings *

Add Another Hazard? *

Hazard #13

Name of Hazard:

Name of Hazard *

Hazard Description *

Hazard Category *

Other Category:

Other Category *

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): *	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level *

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members: *	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings *

Add Another Hazard? *

Hazard #12

Name of Hazard:

Name of Hazard *

Hazard Description *

Hazard Category *

Other Category:

Other Category *

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): *	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level *

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members: *	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings *

Add Another Hazard? *

Hazard #10

Name of Hazard:

Name of Hazard *

Hazard Description *

Hazard Category *

Other Category:

Other Category *

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): *	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level *

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members: *	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings *

Add Another Hazard? *

Hazard #20

Name of Hazard:

Name of Hazard *

Hazard Description *

Hazard Category *

Other Category:

Other Category *

	1	2	3	4	5
Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): *	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 1	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 2	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 3	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 4	Indicate the level of concern this hazard represents in your workplace (1=Highest Concern 5=Lowest Concern): - 5

Concern Level *

	High	Moderate	Low
Rate this hazard for its potential for serious injury or harm to yourself or other staff members: *	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - High	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Moderate	Rate this hazard for its potential for serious injury or harm to yourself or other staff members: - Low

Hazard Ratings *

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Read more about 2019 Risk Assessment Survey

2019 Beyond Hope Session Proposal Form

Are you interested in presenting or participating in a conference session? Please complete and submit the form below. For more information about the conference, visit www.pgpl.ca/beyondhope2019.

Your Name *

Your Email Address *

Your Current Position/Organization *

Your Biographical Info (if presenting)

I will be presenting this session on my own

There will be one or more other people presenting or assisting with the presentation of this session

Presenters *

Other Presenter 1

Name of Other Presenter *

Email Address of Other Presenter *

Current Position/Organization of Other Presenter *

Biographical Info for Other Presenter *

Other Presenter 2

Name of Other Presenter

Email Address of Other Presenter

Current Position/Organization of Other Presenter

Biographical Info for Other Presenter

Other Presenter 3

Name of Other Presenter

Email Address of Other Presenter

Current Position/Organization of Other Presenter

Biographical Info for Other Presenter

Session Title *

Session Description *

Session Duration *

Other Duration: *

Session Date Preference *

Select the day of the conference on which you would prefer to present your session, if applicable. The planning committee will do their best to accommodate date preferences.

No Preference

Monday June 3rd

Tuesday June 4th

Session Cost *

Please indicate whether you intend to charge a fee for presenting this session. Beyond Hope is a small conference--if a speaker fee is desired, please contact Amy Dhanjal at adhangal@pgpl.ca to discuss options and available funding support.

I do not intend to charge any fee for presenting this session

I intend to charge a fee for presenting this session

Additional Comments or Questions

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