Incident Details

Incident information

  • Incident Date

  • Site

  • Site Location

  • Type of Incident

Injury or Illness

    Employee
  • Treatment required

  • Report to WSH, WCB & Health and Safety Program Manager

  • Report to WCB & Health & Safety Program Manager

  • Report to Health & Safety Program Manager

  • Name

  • Sex

  • Shift Start Time

  • Expected Shift End Time

  • Occupation

  • Experience

  • Nature of injury

  • Object/Equipment/Substance inflicting Injury/Damage

Person with most control over item(s) in 11 above

  • Name

  • Job Title

Property Damage

    Property Damaged
  • Description of property

  • Description of Damage

  • Estimated Cost

  • Loss Severity

  • Probable Recurrence Rate

  • Photo of Property Damaged

  • Have lock-out/Tag-out procedure been initiated

Other Loss

    Other Loss
  • Type

  • Description

  • Estimated Cost

  • Loss Severity

  • Probable Recurrence Rate

Details of Incident

  • Description of Incident

  • Photo of Scene

  • Witness(es)

  • Witness
  • Name

  • Statement

  • Immediate Cause

  • Description of immediate cause

  • Underlying Cause

  • Description of underlying cause

  • Corrective Action

  • Person responsible for completion of action

  • Completion required by

Injury or Illness

    Employee
  • Name

  • Treatment required

  • Report to WSH, WCB & Health and Safety Program Manager

  • Report to WCB & Health & Safety Program Manager

  • Report to Health & Safety Program Manager

  • Sex

  • Shift Start Time

  • Expected Shift End Time

  • Occupation

  • Experience

  • Nature of injury

  • Object/Equipment/Substance inflicting Injury/Damage

Person with most control over item(s) in 11 above

  • Name

  • Job Title

Property Damage

    Property Damaged
  • Description of property

  • Description of Damage

  • Estimated Cost

  • Loss Severity

  • Probable Recurrence Rate

  • Photo of Property Damaged

  • Have lock-out/Tag-out procedure been initiated

Other Loss

    Other Loss
  • Type

  • Description

  • Estimated Cost

  • Loss Severity

  • Probable Recurrence Rate

Details of Incident

  • Description of Incident

  • Photo of Scene

  • Witness(es)

  • Witness
  • Name

  • Statement

  • Immediate Cause

  • Description of immediate cause

  • Underlying Cause

  • Description of underlying cause

  • Corrective Action

  • Person responsible for completion of action

  • Completion required by

Property Damage

    Property Damaged
  • Description of property

  • Description of Damage

  • Estimated Cost

  • Loss Severity

  • Probable Recurrence Rate

  • Photo of Property Damaged

  • Have lock-out/Tag-out procedure been initiated

Potential Loss

    Other Loss/Injury
  • Type

  • Description

  • Estimated Cost

  • Loss Severity

  • Probable Recurrence Rate

Details of Incident

  • Description of Incident

  • Photo of Scene

  • Witness(es)

  • Witness
  • Name

  • Statement

  • Immediate Cause

  • Description of immediate cause

  • Underlying Cause

  • Description of underlying cause

  • Corrective Action

  • Person responsible for completion of action

  • Completion required by

  • Supervisor

  • Safety Representative

  • Employee

  • Reporting
    Serious Incident - WSH, WCB & Health & Safety Program Manager
    Medical Treatment - WCB & Health & Safety Program Manager
    First Aid - Health & Safety Program Manager
    Near Miss - Health & Safety Program Manager

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