Accident Incident Investigation Form - Alyeska

• Site conducted

  Select

• Date of Accident / Incident report filled out

  Date

• Completed by

• Document Number

• The responsibility for reporting any injury and requesting first aid or medical aid rests with the colleague. In cases where this is not possible, the Leader is responsible for ensuring that this requirement is met on behalf of the colleague. It is absolutely essential that this report is submitted to provide necessary proof in case of investigation, if a claim develops at a later date. THE LEADER MUST FORWARD THIS REPORT TO THE Director of Facility Operations, WITHIN 24 HOURS OF THE INJURY

Employee Details

• Name:

• Department:

• Position:

• Employment status

  Day Use Labour

  Casual

  Part-time

  Full-Time

• Will the colleague be absent from work because of the injury?

  No

  Unknown

  Yes

• Normal Working Hours Day of Accident: start/finish

• Date and Hour Last Worked: (last shift worked)

  Date

• Next scheduled shift:

  Date

• Normal Work Days

  Select Sunday Monday Tuesday Wednesday Thursday Friday Saturday

  • Sunday
  • Monday
  • Tuesday
  • Wednesday
  • Thursday
  • Friday
  • Saturday

• Normal Working Hours

Details of Accident

• Describe what happened to cause the accident/illness and what the colleague was doing at the time (e.g., lift a 50lb box, slipped on a wet floor, repetitive movements, etc.). Include what the injury is and any details of equipment, materials, environmental conditions (e.g., work area, temperature, noise, chemical, gas, fumes, another person) that may have contributed

• Date and Hour of Accident:

  Date

• Date and Hour Reported:

  Date

• Details of Accident (includes pictures if you can)

• Where exactly did the accident occur? Specify where (e.g., office, vehicle, sidewalk, parking lot) (include pictures if you can)

• Equipment or Object that was involved in the incident (Include pictures if you can)

• Weight of equipment or Object that was involved in the incident: (only required if it resulted in injury such as back injury)

• At the time of the injury was the colleague doing work other than work for Kananaskis Nordic Spa?

  No

  Unknown

  Yes

• Was any individual who does not work for Kananaskis Nordic Spa partially or totally responsible for this accident/illness?

  No

  Unknown

  Yes

• Was the accident/illness: (Please make a selection)

  Select Sudden Specific Event/Occurrence Gradually Occurring Over Time Occupational Disease Fatality

  • Sudden Specific Event/Occurrence
  • Gradually Occurring Over Time
  • Occupational Disease
  • Fatality

• Type of accident/illness: (Please make a selection)

  Struck/Caught

  Overexertion

  Repetition

  Fire/Explosion

  Other

• Did the colleague receive first aid or health care for this injury?

• On Site First Aid

  Yes

  No

  Unknown

• If yes, when was first aid given:

  Date

• Describe First Aid Given:

• Name of First Aid Provider

• Off Site Health Care

  Yes

  No

  Unknown

• If yes, when:

  Date

• What type of Health Care did the colleague receive

  Select Ambulance Hospital Emergency Admitted to Hospital Health Care Professional Office Walk-in Clinic Other

  • Ambulance
  • Hospital Emergency
  • Admitted to Hospital
  • Health Care Professional Office
  • Walk-in Clinic
  • Other

• When did Kananaskis Nordic Spa learn that the colleague received health care?

  Date

• Where was the colleague treated for this injury? (Location)

• Name, address, and phone number of health care professional or facility who treated this colleague (if known)

• Will the colleague require modified duties when they return to work? (please select one)

  Select Return to Work - Regular Duties Return to Work -Modified Duties Lost Time Expected

  • Return to Work - Regular Duties
  • Return to Work -Modified Duties
  • Lost Time Expected

• Has a WCB Employer Report been filed

  Yes

  No

Description of Injury (Body Part)

• Please Check All That Apply

• Area of Injury (Torso/Head)

  Select Head Face Eye(s) Ear(s) Teeth Neck Chest Upper Back Lower Back Abdomen Pelvis

  • Head
  • Face
  • Eye(s)
  • Ear(s)
  • Teeth
  • Neck
  • Chest
  • Upper Back
  • Lower Back
  • Abdomen
  • Pelvis

• Area of Injury (Limbs) - Side of the body affected

  Left Side

  Right Side

• Area of Injury (Limbs) - Specify Limb

  Select Shoulder Arm Elbow Forearm Wrist Hand Finger(s) Hip Thigh Knee Lower Leg Ankle Foot Toes

  • Shoulder
  • Arm
  • Elbow
  • Forearm
  • Wrist
  • Hand
  • Finger(s)
  • Hip
  • Thigh
  • Knee
  • Lower Leg
  • Ankle
  • Foot
  • Toes

Witness(es)

• Is there anyone else who may have witnessed or who may know about the injury and/or accident?

  Yes

  No

  Unknown

• Name(s) of Witness(es)

• Address(es) and phone number(s) if available

• If yes, please provide a copy of the email or text message

LEADER REQUIREMENTS

• If the injury was not reported immediately, provide a reason for the delay

• Are you aware of any prior similar or related problem, injury or condition?

  Yes

  No

• WCB Paperwork Submitted

  Yes

  No

  N/A

• Do you have concerns about this Accident/Incident? If so, please share details

Investigation Of the Accident/Incident?Injury

• What were the causes of the accident/incident/injury? select all that apply in each of the seven categories listed below

• Procedures and Orderliness

  Select Procedures/orderliness inadequate Procedures not followed Procedures not known/understood

  • Procedures/orderliness inadequate
  • Procedures not followed
  • Procedures not known/understood

• Personal

  Stress/Fatigue

  working too quickly

  Lack of Concentartion

• Tools and Equipment

  Wrong for the Job

  Used Incorrectly

  In Unsafe Condition

• Environmental

  Wet Surfaces

  Poor Working Surfaces

  Congestion Clutter

• Personal Protective Equipment

  Not Being Used

  Not Available

  Not Worn Correctly

• Physical

  Select Striking against/struck by object Caught in/on/between objects Falling Contacting Temperature Extremes Contacting Electrical Current Inhaling/absorbing hazardous substances Overexertion Repetitive Motions Awkward Positions

  • Striking against/struck by object
  • Caught in/on/between objects
  • Falling
  • Contacting Temperature Extremes
  • Contacting Electrical Current
  • Inhaling/absorbing hazardous substances
  • Overexertion
  • Repetitive Motions
  • Awkward Positions

• Body Part Requiring Protection

  Select Head Respiratory System Eyes/Face Arms/Hands Ears Trunk Legs/Feet

  • Head
  • Respiratory System
  • Eyes/Face
  • Arms/Hands
  • Ears
  • Trunk
  • Legs/Feet

• Actions to Prevent Reoccurrence Created (create an action using Action icon)

• Leader’s Signature:

  Sign

• Date:

  Date

• JHSC Member Signature

  Sign

• Date:

  Date

• Colleague’s Signature:

  Sign

• Date:

  Date

• Follow up Date: (if required to check on colleagues health)

  Date