Alaska911210

• Site Name

• PM / SM Name:

• Conducted on:

  Date

• When did the incident happen?

  Date

Incident Information

• Has someone been hurt?

  Yes

  No

Injured Person- Basic Information

• Name ( First and Last)

• Contact phone number for injured person

• Role

  Select Contractor PM / SM Employee Client Public Other

  • Contractor
  • PM / SM
  • Employee
  • Client
  • Public
  • Other

• Please specify

• How many hours has the injured person been on shift?

  Select 0-2 hours 2-4 hours 4-6 hours 6-8 hours Greater than 8 hours Not applicable

  • 0-2 hours
  • 2-4 hours
  • 4-6 hours
  • 6-8 hours
  • Greater than 8 hours
  • Not applicable

• Where are they hurt?

  Select Head Face Eye/s Back Body Arm/s Hand/s Leg/s Foot Other

  • Head
  • Face
  • Eye/s
  • Back
  • Body
  • Arm/s
  • Hand/s
  • Leg/s
  • Foot
  • Other

• Please specify

• What type of injury?

  Select Cuts Burns Bruise / Graze Strain / Sprain Electrical Chemical Other Broken bone/s

  • Cuts
  • Burns
  • Bruise / Graze
  • Strain / Sprain
  • Electrical
  • Chemical
  • Other
  • Broken bone/s

• Please specify

• Does the injured person require medical treatment?

  Ambulance

  Hospital

  Doctor

  First Aid

  None

• Has anything been damaged?

  Yes

  No

• What has been damaged?

• Have Police or Fire services been called?

  Yes

  No

Incident Details

• Where did the incident happen?

• Equipment or materials involved:

• Describe the incident

• Please add a photo when applicable

  Media

• Have any actions been taken to prevent this from happening again?

  No

  Yes

• Describe actions taken to prevent this from happening again.

Signature and Review

• I have reported this incident to the best of my knowledge and any actions that can be taken have been done or are planned to prevent recurrence.

• Name of person completing this incident report:

• H&S DEPARTMENT USE ONLY

  Off

  On

Investigation, Preventive Measures and Analysis

• Investigative notes:

• Please add photos when applicable

  Media

• What action has Been taken or is planned to prevent recurrence

  Select Re-Instruction/Retraining Training & Coaching Coaching Training for Leaders Development of Training Improve Procedure Improve Housekeeping Job Hazard Analysis Needed Guard/Safety Device PPE Tools/Equipment Replaced or Repaired Eliminate Congestion Improve Design/Construction Substitute Safer Materials/Supplies/Chemicals Improve Illumination Improve Ventilation Reduction in Noise/Vibration Enforce Procedures Other

  • Re-Instruction/Retraining
  • Training & Coaching
  • Coaching
  • Training for Leaders
  • Development of Training
  • Improve Procedure
  • Improve Housekeeping
  • Job Hazard Analysis Needed
  • Guard/Safety Device
  • PPE
  • Tools/Equipment Replaced or Repaired
  • Eliminate Congestion
  • Improve Design/Construction
  • Substitute Safer Materials/Supplies/Chemicals
  • Improve Illumination
  • Improve Ventilation
  • Reduction in Noise/Vibration
  • Enforce Procedures
  • Other

• How will the above action(s) improve operations?

• Who is responsible for ensuring the above is done?

• When and how will we monitor the effectiveness of the above preventative measures?

Signature and Review

• I have reviewed this report, I am confident that the incident was thoroughly analyzed and proper actions have been taken or are planned to be taken to prevent recurrence.

• Analysis By Health and Safety Advisor