Incident Report

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Information

• Date and time of incident

  Date

• Location of incident. (Specify site location)

• What Type of Incident Occurred?

  First Aid/ Medical

  Property Damage

  Equipment

  Environmental

• Students Name:

• Student's Description of Incident

• Instructor's Name

• Were there any witnesses? If yes, provide names.

First Aid

• Type of Injury

  First-Aid only

  Medical

  Lost time

  OH&S Reportable

  None

• Student Status:

  Returned to Work

  Modified Duties

  Sent Home

  To Doctor

  To Hospital

• Medication prescribed? If yes list medications.

• Detail any first-aid or medical treatment administered. (Provide names)

Property Damage

• What was damaged:

• Photo of damage.

  Media

Environmental

• Was there a spill? If so, What type of product and approximate volume of product spilled

• Does Alberta Environment need to be contacted?

• How was the spill contained and cleaned up?

• Environmental photo:

  Media

Investigation

• Detailed description of incident. (Include environmental conditions at time of incident)

• Immediate (Direct Causes):

• Contributing (underlying) Factors:

• Contributing factors photo:

  Media

• Corrective Action (Include detail description of action and person(s) responsible for actions)

• What was the potential for severity?

  Minor

  Serious

  Major

• What could have potentially happened?

• What is the probability of reoccurrance?

  Remote

  Improbable

  Probable

Signatures

• Student Signature

  Sign

• Instructor Signature

  Sign