1. Accident/Incident Details

  • 1a. Employee / Injured Party Name:

  • 1b. Was injury or incident reported immediately? (To whom)

  • 1c. Date & Time reported:

  • 1d. Is the injured party an employee of JMCC? If the answer is no, list Sub-Contractor or Affiliation to project.

  • 1e. Trade:

  • 1f. Indicate Employees Union Local affiliation:

  • 1g. Location of accident (please be specific)

  • 1h. Date and time of injury;

  • 1i. Describe nature of injury:

  • 1j. Describe what employee was doing at the time of injury:

  • 1k. Was employee working on assigned task? Give details.

  • 1l. Who assigned task to employee?

  • 1m. Was a Pre-Task / Tool box Talk training completed before work began? (Attach Copies)

  • 1n. Photograph copies of training documents (attach here)

2. Statements: Witness, Employee, & Foreman

  • 2a. What were fellow co-workers / trades assignment at the time of injury?

  • 2b. Were co-workers or other tradesmen present at time of injury? (List individually)

  • 2c. Were there any witnesses?

  • 2d. Witness Statement:

  • 2e. Witness

  • 2f. Witness Signature:

  • 2g. Foreman Statement:

  • 2h. Foreman Signature:

  • 2i. Employee Statement:

  • 2j. Employee signature:

  • 2k. Describe who, what, when,where, why and how injury occurred:

  • 2l. photo of work area

  • 2m. photo of task and body position

  • 2n. Photo of injury (if possible)

3. Contributing Causes:

  • 3a. Were tools being carried or used at time of incident

  • 3b. Describe tools being used or carried at time of incident:

  • 3c. Did the use of tools, equipment or material play a role in this incident?

  • 3e. Describe how tools, equipment or material affected this incident:

  • 3f. Were photo's taken at time of incident by anyone else beside person completing this form?

  • 3g. Who took other photo's and what is their affiliation to the project? (Please List with contact info)

  • 3h. Contributing Cause or Causes of the incident: (Inadequate PPE, Not Paying attention to surroundings, failure to utilize safety equipment)

  • 3i. Were any chemicals involved in incident?

  • 3j. Describe chemical label on can and SDS (aka) MSDS for chemical.

  • 3k. Photographs of label if possible.

4. Injury Details

  • 4a. Was first aid provided at time of injury?

  • 4b. Did employee decline medical treatment at time of injury?

  • 4c. Was post accident drug testing performed?

  • 4d. Did injured employee go to clinic to receive medical attention for injury?

  • 4f. Name and Location of assigned facility.

  • 4g. Was employee released to full / regular duty?

  • 4h. Was the employee released to work with restrictions?

  • 4i. Describe in detail restrictions:

  • 4j. Is there a follow up appointment, if so when? (Select date & time)

  • 4k. Is there a light duty position available based on restrictions?

5. Corrective Action: Short Term

  • 5a. What was the immediate action taken to correct the issue (how was this done):

6. Corrective Action: Long Term

  • 6a. What are the long term corrective action or actions needed to correct and avoid this issue? (describe)

7. Additional Information

  • 7a. Drawings applicable to Incident

  • 7b. Are there any attachments that apply: Pictures, Drawings, Training Records, Statement of Employee, Statement of Witness/es, Other.

  • 7c. Attachment Details here:

  • 7d. Additional Information notes:

8. Person Completing Form (please sign below)

  • 8a. Investigation by:

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