Type of incident:

  • Illness

  • Injury

  • Fire/Explosion

  • Vehicle Accident

  • Property Damage

  • Unexpected Exposure

  • Health and Safety Infraction

  • Other: Describe:

  • Tap to enter information

What was employee doing"

  • Tap to enter information

What Happened?

  • Tap to enter information

What caused the accident (root cause)?

  • Tap to enter information

Pictures. Take pictures of the scene to document.

  • Click here to enter media:

  • Tap to enter information and further notes as needed.

Corrective Actions recommended:

  • Tap to enter information

Corrective Actions

  • Enter any corrective actions that will be undertaken

Sign Off

  • On site representative

  • JCC safety committee signature

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