Information
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Division Where Incident Occurred:
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Address / Location of Incident:
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Did an Injury Occur?
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Date / Time of Incident:
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Members of the Investigation Team:
Part 1 : Particulars
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Did the incident involve injury?
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Name of Injured Worker:
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Injured Worker's Occupation / Job Title:
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Nature of Injury:
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Supervisor's Name:
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Did the incident involve property damage?
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Describe the nature of the property damage:
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Was first aid rendered?
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If yes, by whom? (If outside emergency assistance was required, provide details)
Part 2 : Description of Incident
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Describe the incident in detail:
Part 3 : Evidence
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Sketch of the Incident Scene:
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Describe the physical evidence collected:
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List and Describe the photos and videos:
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Photo / Video Evidence:
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Were there any witnesses to this incident?
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Witness Name:
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Contact information for witness if he / she is not an employee of Kroeker Farms Limited
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Occupation:
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Date of the Interview:
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Name of Interviewer:
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Summary of Witness' Statement:
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Signature of Witness: I hereby state that the above summary is an accurate and complete statement of what I saw take place.
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Witness Name:
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Contact information for witness if he / she is not an employee of Kroeker Farms Limited
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Occupation:
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Date of Interview:
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Name of Interviewer:
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Summary of Witness' Statement:
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Signature of Witness: I hereby state that the above summary is an accurate and complete statement of what I saw take place.
Part 4 : Incident Causation
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What was the DIRECT CAUSE of the incident? (What caused injury or damage?)
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What was the INDIRECT CAUSES? (What caused the incident?)
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TASK:
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WORKER(S):
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MATERIAL / EQUIPMENT:
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MANAGEMENT:
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ENVIRONMENT:
Part 5 : Corrective Acrion
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Immediate corrective actions to prevent recurrence:
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Target Date for completion of Corrective Action:
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Long term solutions:
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Target Date for Long Term Solutions:
Report Review:
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Signature of Investigator:
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Signature of Investigator:
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Signature of Investigator:
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Date Report Completed:
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Distribute Report to:
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Signature of Safety Committee Employer Co-Chair:
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Signature of Safety Committee Worker Co-Chair:
