Accident/Incident Details

  • Employee / Injured Party Name:

  • Is the injured party an employee of JMCC? If the answer is no, list Sub-Contractor or Affiliation to project.

  • Trade:

  • Indicate Employees Union Local affiliation:

  • Date and time of injury;

  • Describe nature of injury:

  • Describe what employee was doing at the time of injury:

  • Was employee working on assigned task? Give details.

  • Who assigned task to employee?

  • Was a Pre-Task / Tool box Talk training completed before work began? (Attach Copies)

  • Photograph copies of training documents (attach here)

  • What were fellow co-workers / trades assignment at the time of injury?

  • Were co-workers or other tradesmen present at time of injury? (List individually)

  • Were there any witnesses?

  • Witness Statement:

  • Witness

  • Witness Signature:

  • Employee Statement:

  • Employee signature:

  • Location of accident (please be specific)

  • Describe who, what, when,where, why and how injury occurred:

  • photo of work area

  • photo of task and body position

  • Photo of injury (if possible)

  • Were tools being carried or used at time of incident

  • Describe tools being used or carried at time of incident:

  • Did the use of tools, equipment or material play a role in this incident?

  • Describe how tools, equipment or material affected this incident:

  • Were photo's taken at time of incident by anyone else beside person completing this form?

  • Who took other photo's and what is their affiliation to the project? (Please List with contact info)

  • Contributing Cause or Causes of the incident: (Inadequate PPE, Not Paying attention to surroundings, failure to utilize safety equipment)

Injury Details if Applicable

  • Was first aid provided at time of injury?

  • Did employee decline medical treatment at time of injury?

  • Did injured employee go to clinic to receive medical attention for injury?

  • Name and Location of assigned facility.

  • Were any chemicals involved in incident?

  • Describe chemicals and photo label on can and photo of SDS (aka) MSDS for chemical.

  • Add media

  • What is the employee's current status if injured: Describe. ( Returned to work the next day, off of work due to injury, off of work due to restrictions, In hospital, etc.)

  • Was employee released to full / regular duty?

  • Was post accident drug testing performed?

  • Was the employee released to work with restrictions?

  • Describe in detail restrictions:

  • Is there a follow up appointment, if so when? (Select date & time)

  • Is there a light duty position available based on restrictions?

Action: Short Term

  • What was the immediate action taken to correct the issue (how was this done):

Action: Long Term

  • What are the long term action or actions needed to correct and avoid this issue? (describe)

Additional Information

  • Drawings applicable to Incident

  • Are there any attachments that apply: Pictures, Drawings, Training Records, Statement of Employee, Statement of Witness/es, Other.

  • Attachment Details here:

Person Completing Form (please sign below)

  • Investigation by:

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