Persons involved:

  • Number of Workers involved:

  • Name of worker:

  • Workers Man #:

  • Name of worker:

  • Worker Man #:

  • Name of Worker:

  • Worker Man #:

  • Name of worker:

  • Worker Man #:

  • Name of worker:

  • Worker Man #:

  • Name of worker:

  • Worker Man #:

  • Worker Name:

  • Worker Man #:

  • Worker Name:

  • Worker Man #:

  • Worker Name:

  • Worker Man #:

  • Worker Name:

  • Worker Man #:

  • Provide Workers Names and Man #:

  • First aid attendant:

  • Company

  • Superintendent

  • Head Foreman

  • Foreman

Incident:

  • What type of incident is being investigated?

  • Specific location: (Yard Location, Berth, Hatch #, Ect)

  • Incident description:

  • Was there a "Tool Box Talk"

  • Explain conflict:

  • Was first Aid on scene?

  • Was Worker(s) using proper PPE: (Boots, Hi-Viz Vest, Gloves, Type 2 Hard Hat)

  • Was Worker(s) Provide with Additional PPE:

  • Fall Protecton

  • Eye Protection

  • Special Gloves

  • Mask or Resperator

  • Coveralls

  • Life Jacket

  • Caulk Boots

  • Was a Worker(s) injured?

  • Nature of injury

  • Worker(s) statements:

  • Was Fire and Rescue used?

  • Was a Ambulance required?

  • Damage:

  • Were there witnesses:

  • Witness Info: (Name, Man #, Contact info)

  • Witness statements

  • Did Superintendent/ Foreman make a Statement:

  • Superintendant/ Foreman's Statement:

  • Was a "SOP" Safe Operating Procedure Being Followed:

  • Root Cause and Contributing Factors:

  • Actions taken:

  • Investigator Recommendations:

  • Nature of complaint

  • Person making complaint:

  • Complaint is against:

  • Complaint is against: (Name, Man #)

  • Specific Location (Yard Location, Hatch #, Building, Ect)

  • Accuser statement:

  • Was there witness(es):

  • Witness(es) Info: (Name, Man #, Contact info)

  • Witness statements

  • Accused Statement:

  • Actions taken

  • Investigator Recommendations:

  • Specific Location (Yard Location, Hatch #, Building, Ect)

  • Was there a "Tool Box TALK" :

  • Explain Conflict:

  • Incident description:

  • Statements from worker(s):

  • Did superintendent or Forman make a statement?

  • Superintendent/ Foremen statement:

  • Were there any other witnesses?

  • Witness Statements:

  • Damage :

  • Was a third party used? (Marine tech/ Transport Canada/ Esdc)

  • Third party notes/ Recommendations/ Statements

  • Was a "SOP" Safe Operating Procedure Being Followed:

  • Root cause and contributing factors:

  • Investigator Recommendations:

  • Actions taken:

  • What is the nature of the health complaint?

  • What chemical was spilled/ leaked?

  • Was First Aid Required?

  • Was a Worker(s) physically effected?

  • Through what means did a worker come in contact with the chemical? (If any)

  • Worker(s) Statment:

  • Statment:
  • Was the source of the leak labeled properly?

  • Was information on the chemical requested?

  • Was information on the chemical provided?

  • What information was provided?

  • Cause of leak or spill:

  • Was Emergency response required?

  • Who Responded?

  • Was a third party used to identify/ sample/ clean/ deem safe:

  • Third party's statement/ recommendations:

  • Actions taken:

  • What is the nature of the biological complaint?

  • Incident description:

  • Was First Aid required?

  • Were workers physically affected?

  • How was worker(s) exposed to Biological material?

  • Worker(s) statment:

  • Statement:
  • Was Emergency response required?

  • Who Responded?

  • Was a third party used to identify/ sample/ clean/ deem safe:

  • Third party's statement/ recommendations:

  • Actions Taken:

  • Location of health complaint:

  • Was a first aid report completed?

  • Was worker injured?

  • Workers Statements
  • This injury would be considered a:

  • Has this concern been addressed by a third party expert?

  • Third party statement/ recommendations:

  • Actions taken:

Additional Info and Photos

  • Notes:

  • Photos

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