Title Page
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Employee Name
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Date of Accident
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Today's Date
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Prepared by
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Location of Accident
Employee Information
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Please select the type of incident:
EMPLOYEE DATA
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Employee Name:
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Department:
- Building Services
- Custodial Services
- Maintenance Programs
- Grounds and Equipment
- Utility Services
- Renovation Services
- OPP Stores
- Facility Automation
- Staff
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Work Group:
- Area Services 1
- Area Services 2
- Area Services 3
- Area Services 4
- Area Services 5
- Area Services 6
- Weekend Trades
- Plumbing/Metal Fab
- HVAC
- General Services
- Electrical/Electronics
- Second Shift Trades
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Work Group:
- District 11
- District 21
- District 31
- District 41
- District 51
- District 12
- District 22
- District 32
- District 42
- District 52
- District 62
- District 13
- District 23
- District 33
- District 43
- District 53
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Work Group:
- Elevator/Vibration
- Hydronic Programs
- HVAC PM
- Electrical Integrity
- Electrical PM
- Roofin g/General Maintenance
- Environmental Services
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Work Group:
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Work Group:
- Water Services
- Waste Water Services
- Central Chiller Water Services
- Utility Construction
- Electrical Services
- Steam Distribution
- Steam Plant Operations
- Steam Plant Maintenance
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Work Group:
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Work Group:
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Work Group:
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Work Group:
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Job Title:
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Shift:
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Status:
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How long have you been employed at OPP:
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Date and Time of accident:
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Safety office notified within 24 hours.
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Supervisors Name:
Accident Data/Contributing Factors
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Detailed narrative of how incident occurred:
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Add pictures here:
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What was the employee doing just prior to accident? (job task, include tools and machinery)
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Body part injured:
- Head/eye/face
- Neck
- Left Shoulder
- Right Shoulder
- Upper Back
- Lower Back
- Left Arm/hand
- Right Arm/hand
- Left Leg/knee/foot
- Right Leg/knee/foot
- Torso/mid section
- Other
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Please describe:
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Type of Injury:
- Sprain
- Strain
- Laceration
- Puncture
- Amputation
- Contusion
- Foreign body
- Exposure
- Other
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Please describe:
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Weather Conditions at time of accident:
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Visibility/Lighting:
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Type and condition of floor or working surface:
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PPE Required for the job: (select all that apply)
- Hard Hat
- Safety Glasses
- Safety Shoes
- Hearing Protection
- Face Shield
- Respirator
- Protective Clothing
- Gloves
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Was the required PPE in use at time of the accident?
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Was there any damage to property or equipment?
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Please explain:
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Did anyone witness the accident?
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Witness Information:
Causes: Please check all of the following which contributed to the injury or illness:
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Direct / Immediate Causes:
- Defective Tools or Equipment
- Unsafe Work Procedures
- Insufficient Procedures
- Not Following Procedures
- Improvising/Shortcuts
- Unaware of Potential Hazard
- Lack of Safety Devices
- Not Employees Normal Job
- Improper Use of Tools
- Proper Tools Not Available
- Unauthorized Equipment Use
- Guard Removed/Needed
- Poor Housekeeping
- Violated Safety Rule
- Not Wearing Proper Equipment
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Root Causes:
- Employee Unaware of Hazard
- Complex Procedures
- Unclear Instruction
- Inadequate Training
- Inadequate Comprehension
- Lack of Skill/Knowledge
- Failure to Recognize Unsafe Act
- Poor Attitude
- Personality Conflict
- Lack of Training
- Job Design/Work Station Layout
- Lighting
- Equipment Maintenance
- Weather Condition
- Excessive Production Pressure
- Communication Error
- Lack of Employee Cooperation
- Other
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Please Explain:
Corrective Actions
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Recommended Engineering Control, Training, or Program/Policy Change:
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Remedial Training:
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Was a work order or a project request submitted for solutions?
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Please provide details of request, including job/project number and a deadline for completion:
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What action was or should be taken to prevent recurrence?
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Were corrective actions completed?
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Please explain:
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Investigated by:
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Reviewed by:
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Date Completed
