Employee Information

Last Name:  

First Name:  

Middle Initial(s):  

Work Phone Number:  

Home Phone Number:  

Employment Information

Site Location:  

Employee #:  

Date of Hire:  

Language (If other than English):  

Occupation / Job at Time of Incident:

Length of Time in Occupation / Job:

______ Years  ______ Months  ______ Days

Type of Employment (check all which apply):  Full Time   Part Time   Hourly   Salary   Casual

Contractor Name of Company:  

Details of Investigation

Site:  

Department:  

Exact Location of Incident on the Premises:

Immediate Supervisor:  

Incident Date:                Month:                    Day:                    Year:               Time:                am [   ]  pm [   ]

Date Reported:                Month:                    Day:                    Year:               Time:                am [   ]  pm [   ]

Date of Investigation:        Month:                    Day:                    Year:               Time:                am [   ]  pm [   ]

TYPE:         Incident         Near Miss         Property Damage         Spill / Release

WCB Report required:  Yes   No                WCB Report Completed:   Yes   No

INJURY / ILLNESS:   None   First Aid   Medical Aid   Hospital   Fatality

No Lost Time   Lost Time

Part of Body Injured:  (Provide a detailed description and specify left or right, front or back)  

Has the injured worker had a previous similar injury?   Yes   No        (If yes, describe in detail)

Medical Treatment Information

Name of First Aid Attendant:  

Injury Recorded in First Aid Log?   Yes   No

Type of First Aid Administered:  

Clinic / Hospital sent to:  

Attending Physician / Paramedic (if known):  

Attending Police Officer (if known):  

(B) – Property

Property Damaged:  

Estimated Cost of Damage:  $

Description of Damaged Property:  

(C) – Witness Information

Number of Witnesses:  _____ ATTACH WITNESS STATEMENT(S) FOR EACH WITNESS

Investigation Information

Type of Incident:  Assault   Break   Caught In   Caught On   Caught Between   Cut On   Exposure   Fall   Over Exertion   Strain   Struck By   Struck Against   Trip   Other (specify):  

Contact With: Cold   Heat   Electricity   Fire   Noise   Pressure   Equipment

Caustic Chemical (specify):_________________________   Toxic Chemical (specify):______________________   Other (specify):______________________________

Describe in detail the SEQUENCE OF EVENTS leading up to the incident.  (ie. Where the incident occurred: what the employee was doing at the time: the size, type and weight of equipment or materials involved: weather conditions, etc.).  Use additional pages if required and provide diagrams, photographs and reports.

Diagram / Photographs attached     Yes   No

ALL EVIDENCE / INFORMATION GATHERED FOR INVESTIGATION TEAM ONLY

Identify all UNSAFE ACTS which contributed to the incident: (check off as many as necessary)

Operating Without Authority

Horseplay

Servicing Operating Equipment

Unsafe Loading / Unloading

Inadequate Lighting

Using Defective Tools

Unsafe Mixing / Combining

Working at Unsafe Speed

Using Defective Equipment

Failure to Wear Proper PPE

Distracting

Working on Moving Equipment

Failure to Warn Properly

Teasing  

Improper Lifting

Failure to Secure Properly

Harassment

Unfit for Duty (possible impairment)

Unsafe Position or Posture

Hazardous Personal Attire

Making Safety Device Inoperable

Other (specify):

Identify all UNSAFE CONDITIONS which contributed to the incident: (check off as many as necessary)

Inadequate Guards / Barriers

Gases  

Hazardous Environmental Conditions

Improper or Inadequate PPE

Dusts

Extreme Weather Conditions

Inadequate Lighting

Fumes  

Extreme Temperature(s)

Unsafe Job Design

Vapours

Noise Exposure

Congested Work Area

Smoke  

Unsafe Mobile Equipment

Inadequate Warning Systems

Explosion Hazard

Defective Tools or Equipment

Poor Housekeeping

Fire Hazard

Defective Materials

Other (specify):

Identify all INDIRECT CAUSES which contributed to the incident: (check off as many as necessary)

Personal Factors

Job Factors

Inadequate Physical Capability

Inadequate Leadership or Supervision

Abuse or Misuse of Equipment

Inadequate Engineering Controls

Physical Stress

Inadequate Purchasing

Mental Stress

Inadequate Maintenance (scheduled or preventative)

Lack of Knowledge

Inadequate Tools or Equipment

Lack of Skill

Inadequate Work Standards

Improper Motivation

Wear and Tear

Identify all ROOT CAUSES which contributed to the incident:   (check off as many as necessary)

Management Commitment & Administration

Emergency Preparedness and Response

Leadership Training

Company Safety Rules and Work Permitting

Planned Inspections

Worker Knowledge & Skill Training

Preventive Maintenance

Personal Protective Equipment (PPE)

Hazard Identification

Personal or Group Communications

Safe Work Practices and/or Procedures

Hygiene and Sanitation

Inadequate Previous Incident Investigation

Hiring & Placement Standards

Purchasing Controls

Other(s):

(E) - Prevention

(Number those actions required to Prevent Recurrence of a similar incident, 1 being most critical in order of priority)

Training / Retraining of Involved Worker(s)

Improve Safety Inspection Process

Job Procedure / Design Changes

Reassignment of Involved Worker

Equipment Repair or Replacement

Liaison with Manufacture of Equipment / Tool

Perform in-depth Hazard Identification

and Analysis

Facilities Layout Review and Redesign

Improved Hazard Controls

(engineering / admin. / PPE)

Installation of Safety Guards / Barriers

Supervisory Communication

Other (specify):

Describe Action(s) Taken to Prevent Recurrence (short term and long term):

Assignment of Action Item(s)

Action item:

Responsible:

Date of completion:

Sign-off:

Action item:  

Responsible:

Date of completion:

Sign-off:

Action item:  

Responsible:

Date of completion:

Sign-off:

Investigation Team (First & Last Names)

Lead Investigator:  

Position & Department:  

Investigator:  

Position & Department:  

Investigator:  

Position & Department:  

Lead Investigator Comments:  

Lead Investigator Name (print):                        Signature:                                Date:

Involved Worker(s) Comments:  

 Employee Statement Attached:  

Employee Name (print):                                Signature:                                Date:  

Additional Management Comments:  

Manager Name (print):                                        Signature:                                Date:

Investigation Number: