Incident Report Form

SECTION A - Incident Information

• Site conducted

  Select

• Province / Territory

• Closest Town

• Project Code

• Report Number

• Report Date

  Date

• Prepared by

• Your Position/Role

Person Involved

• Name

• Position/Role

• Company

• Incident Date & Time

  Date

• Incident Report Date & Time

  Date

• Where did the incident occur? (ex. parking lot, field)

• Describe the conditions (eg, Environs such as heat / rain, Visibility and Ground Conditions)

• Briefly describe the incident:

• List any attached statements, photos or diagrams

• Initial actions taken: (ex. FA provided, medevac, stopwork)

• Was the Emergency Response Plan initiated?

• Did Emergency Services respond to the scene?

Classification of the incident (Y/N) (can be multiple)

• Near Miss (Minor)

• Minor Injury (No Treatment)

• First Aid Treatment

• Medical Treatment Injury

• Illness

• Restricted Work

• Lost Time Injury

• *Serious Injury (Report Immediately)

• *Fatality (Report Immediately)

• *Reportable Incident (Report Immediately)

• Environmental/Wildfire

• Property Damage/Loss

• Community/Cultural

• Financial Loss

• Breach of Law/Regs

• Breach of Agreement

• Lost/Stopped Work

• Harassment/Bullying

SECTION B: Preliminary Investigation. Include workers, follow investigation guide, assign actions to prevent incident recurrence. This is not a full investigation.

• Workers Included

• List standard controls for the activity

• Were there controls not in place or that failed? Describe

• List conditions, acts or procedures that significantly contribute to the incident, (use Step Backwards exercise)

• Why did the conditions/acts/procedure happen? (use 5 Whys exercise)

What controls should be put in place immediately to prevent reoccurrence?

• Action/Control

• Responsible

• Implement by Date

  Date

• Action/Control

• Responsible

• Implement by Date

  Date

• Action Control

• Responsible

• Implement by Date

  Date

Reporting Person

• Print Name

• Sign

  Sign

• Date

  Date

If multiple people experienced injury/illness, attach additional pages. Completed First Aid forms should remain on site.

• Name of person injured/ill

• Gender

  Male

  Female

  Other

• Position/Role

• Company

• Description of injury/illness

• Body part injured

• Are you aware of any prior injury/condition? If yes, describe the injury/condition.

• Was First Aid given?

• Date of first aid

  Date

• Was the worker treated by a medical professional? Go to a hospital or clinic?

  Yes

  No

  N/A

• Facility/Provider name

• Date of treatment

  Date

• Did the worker miss schedule time beyond the day of injury?

  Yes

  No

  N/A

• Date of return to work (if applicable)

  Date

• Did the worker require alternate/modified duties?

  Yes

  No

  N/A

• Describe alternate/modified duties?