Incident Report

• Job location

  Artesao De Luxo - Wetaskiwin

  Artesao Handrails - Millet

  Travel

• Conducted on

  Date

• Form prepared by

• Location of incident (indoors/outdoors/toilet/etc.)

• NOTE:
  

Incident Details

• Enter job description

• Date and time of incident

  Date

• What was the Incident/ Near Miss?

• Were there any injuries?

  Yes

  No

• Was first aid reqiured

  Yes

  No

• What first aid was completed

  Yes

  No

  N/A

• Was hospital transport required?

  Yes

  No

  N/A

• Was 911 called and ambulance transported?

  Yes

  No

  N/A

• Description of injury

• Take photo of injury if applicable

  Media

• Yes

  No

  N/A

• Was there any damage to property?

  Yes

  No

• Description of damage

• Take photo of damage

  Media

• What caused the incident?

• Take photo of surrounding environment and include any descriptions

  Media

• What actions should be taken to eliminate future repeats of the incident?

• Management comments

Sign Off

• Witness to incident?

  Yes

  No

• Name and phone number of witness

• Signed off by supervisor when corrective actions have been adopted and monitored

• Supervisor sign off

  Sign