OH&S Investigation

• Audit Title

• Document No.

• Conducted on

  Date

• Prepared by

• Prepared for:

• Location
  Address

• Dock/ Vessel

Persons involved:

• Number of Workers involved:

  1

  2

  3

  4

  5+

• 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?

  Accident

  Harassment

  Near miss

  Occupational Health

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

• Incident description:

• Was there a "Tool Box Talk"

  Yes

  No

  Conflicting Reports

• Explain conflict:

• Was first Aid on scene?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Was Worker(s) Provide with Additional PPE:

  Yes

  No

  N/A

• Fall Protecton

• Eye Protection

• Special Gloves

• Mask or Resperator

• Coveralls

• Life Jacket

• Caulk Boots

• Was a Worker(s) injured?

  Yes

  No

  Multiple injuries

• Nature of injury

  Disabling

  Medical aid

  First Aid

  First Aid (Return to work)

  Retuned to work

• Worker(s) statements:

• Was Fire and Rescue used?

  Yes

  No

  N/A

• Was a Ambulance required?

  Yes

  No

  N/A

• Damage:

  Machinery

  Property

  Cargo

  Stevedore gear

  No damage

• Were there witnesses:

  Yes

  No

  N/A

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

• Witness statements

• Did Superintendent/ Foreman make a Statement:

  Yes

  No

  Refused

  Pending

• Superintendant/ Foreman's Statement:

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

  Yes

  No

  No "SOP" for Operation

• Root Cause and Contributing Factors:

• Actions taken:

• Investigator Recommendations:

• Nature of complaint

  Bullying

  Harassment

  Violence

• Person making complaint:

• Complaint is against:

  union member

  Casual

  Foreman

  Superintendent

• Complaint is against: (Name, Man #)

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

• Accuser statement:

• Was there witness(es):

  Yes

  No

  N/A

• 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" :

  Yes

  No

  Conflicting Reports

• Explain Conflict:

• Incident description:

• Statements from worker(s):

• Did superintendent or Forman make a statement?

  Yes

  No

  Refused

  Pending

• Superintendent/ Foremen statement:

• Were there any other witnesses?

  Yes

  No

  N/A

• Witness Statements:

• Damage :

  Machinery

  Property

  Cargo

  Stevedore gear

  No damage

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

  Yes

  No

  N/A

• Third party notes/ Recommendations/ Statements

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

  Yes

  No

  No "SOP" for Operation

• Root cause and contributing factors:

• Investigator Recommendations:

• Actions taken:

• What is the nature of the health complaint?

  Chemical

  Biological

  Ergonomic

• What chemical was spilled/ leaked?

• Was First Aid Required?

  Yes

  No

  N/A

• Was a Worker(s) physically effected?

  Yes

  No

  N/A

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

  Ingestion

  Absorbstion

  Inhalation

  Injection/ Puncture skin

  No contact

• Worker(s) Statment:

Statment:

• Was the source of the leak labeled properly?

  Yes

  No

  N/A

• Was information on the chemical requested?

  Yes

  No

  N/A

• Was information on the chemical provided?

  Yes

  No

  N/A

• What information was provided?

• Cause of leak or spill:

• Was Emergency response required?

  Yes

  No

  N/A

• Who Responded?

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

  Yes

  No

  N/A

• Third party's statement/ recommendations:

• Actions taken:

• What is the nature of the biological complaint?

  Unsanitary conditions

  Mould/ fungus

  Human waste/ Fluid

  Allergic reaction

• Incident description:

• Was First Aid required?

  Yes

  No

  N/A

• Were workers physically affected?

  Yes

  No

  N/A

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

  Ingestion

  Absorbstion

  Inhalation

  Injection/ Puncture skin

  No contact

• Worker(s) statment:

Statement:

• Was Emergency response required?

  Yes

  No

  N/A

• Who Responded?

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

  Yes

  No

  N/A

• Third party's statement/ recommendations:

• Actions Taken:

• Location of health complaint:

• Was a first aid report completed?

  Yes

  No

  N/A

• Was worker injured?

  Yes

  No

  N/A
Workers Statements

• This injury would be considered a:

  Repetitive strain injury

  Static injury

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

  Yes

  No

  N/A

• Third party statement/ recommendations:

• Actions taken:

Additional Info and Photos

• Notes:

• Photos

  Media