Incident Investigation

• Incident Investigation

• Investigation Name

• Conducted on

  Date

• Prepared by

• Location
  Address

Incident information

• Incident Date

  Date

• Site

• Site Location

• Type of Incident

  Near Miss

  Minor

  Serious

Injury or Illness

Employee

• Treatment required

  Serious

  Medical Treatment

  First Aid

  Near Miss

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

• Report to WCB & Health & Safety Program Manager

• Report to Health & Safety Program Manager

• Name

• Sex

  Male

  Female

• Shift Start Time

  Date

• Expected Shift End Time

  Date

• 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

  Immediate Danger: Death

  Serious: Major Injury or Damage

  Minor: Medical Treatment

  Negligable: First Aid or less

  Not Applicable

• Probable Recurrence Rate

  Probable: Immediately or Soon

  Reasonably Probable: Eventually

  Remote: Could at some point

  Extremely Remote: Not likely

• Photo of Property Damaged

  Media

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

Other Loss

Other Loss

• Type

• Description

• Estimated Cost

• Loss Severity

  Immediate Danger: Death

  Serious: Major Injury or Damage

  Minor: Medical Treatment

  Negligable: First Aid or less

  Not Applicable

• Probable Recurrence Rate

  Probable: Immediately or Soon

  Reasonably Probable: Eventually

  Remote: Could at some point

  Extremely Remote: Not likely

Details of Incident

• Description of Incident

• Photo of Scene

  Media

• 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

  Date

Injury or Illness

Employee

• Name

• Treatment required

  Serious

  Medical Treatment

  First Aid

  Near Miss

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

• Report to WCB & Health & Safety Program Manager

• Report to Health & Safety Program Manager

• Sex

  Male

  Female

• Shift Start Time

  Date

• Expected Shift End Time

  Date

• 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

  Immediate Danger: Death

  Serious: Major Injury or Damage

  Minor: Medical Treatment

  Negligable: First Aid or less

  Not Applicable

• Probable Recurrence Rate

  Probable: Immediately or Soon

  Reasonably Probable: Eventually

  Remote: Could at some point

  Extremely Remote: Not likely

• Photo of Property Damaged

  Media

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

Other Loss

Other Loss

• Type

• Description

• Estimated Cost

• Loss Severity

  Immediate Danger: Death

  Serious: Major Injury or Damage

  Minor: Medical Treatment

  Negligable: First Aid or less

  Not Applicable

• Probable Recurrence Rate

  Probable: Immediately or Soon

  Reasonably Probable: Eventually

  Remote: Could at some point

  Extremely Remote: Not likely

Details of Incident

• Description of Incident

• Photo of Scene

  Media

• 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

  Date

Property Damage

Property Damaged

• Description of property

• Description of Damage

• Estimated Cost

• Loss Severity

  Immediate Danger: Death

  Serious: Major Injury or Damage

  Minor: Medical Treatment

  Negligable: First Aid or less

  Not Applicable

• Probable Recurrence Rate

  Probable: Immediately or Soon

  Reasonably Probable: Eventually

  Remote: Could at some point

  Extremely Remote: Not likely

• Photo of Property Damaged

  Media

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

Potential Loss

Other Loss/Injury

• Type

• Description

• Estimated Cost

• Loss Severity

  Immediate Danger: Death

  Serious: Major Injury or Damage

  Minor: Medical Treatment

  Negligable: First Aid or less

  Not Applicable

• Probable Recurrence Rate

  Probable: Immediately or Soon

  Reasonably Probable: Eventually

  Remote: Could at some point

  Extremely Remote: Not likely

Details of Incident

• Description of Incident

• Photo of Scene

  Media

• 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

  Date

• Supervisor

  Sign

• Safety Representative

  Sign

• Employee

  Sign

• 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