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

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.