Report an Incident at Dortec Newmarket

• Conducted on

  Date

• Prepared by

• Location
  Address

• What type of incident is this?

  Select Discomfort/Ergonomics Near Miss First Aid Medical Aid Significant Injury/Critical Injury Property Damage

  • Discomfort/Ergonomics
  • Near Miss
  • First Aid
  • Medical Aid
  • Significant Injury/Critical Injury
  • Property Damage

• STOP: If you selected Significant/Critical Injury - you must speak to Jillian, Jennifer or Gina before proceeding. Refer to the Critical Injury Kit in the D1 First Aid Room for more information.

Employee Information

• Worker's Name

• Worker's Employee Number

• Worker's Current Phone #

• Worker Status

  Full Time

  Contract

  Temporary Agency

  Contractor

  Other

Incident Information

• Incident Location

  D1

  D2

• Location details (i.e. warehouse, assembly line and station #, office area)

• Date and time of incident

  Date

• Date and time reported to supervisor

  Date

• Did the worker report on the same day as the incident?

  Yes

  No

  N/A

• If not, explain why?

• Incident description (what happened?)

• Were there any witnesses to the incident?

  Yes

  No

  N/A

• Ensure individual witness statements are taken and submitted to Human Resources immediately.

• Were any Dortec Safety Rules broken?

  Yes

  No

  N/A

• Which one(s)? Reference the handbook or any relevant policies

• Please follow up with the Human Resources team as soon as possible to discuss this incident.

Incident Investigation

• Was the injury work related?

  Yes

  No

  N/A

• Injury description (be detailed as possible)

• Did the worker receive first aid?

  Yes

  No

  N/A

• Who provided first aid?

• Did the worker receive medical attention (more than first aid - such as hospital, clinic or family doctor)

  Yes

  No

  N/A

• Where did they receive medical attention? Please put clinic/hospital/doctor's name.

• When did they receive medical attention?

  Date

• Is the worker able to continue their regular duties?

  Yes

  No

  N/A

• Was modified work offered?

  Yes

  No

• Ensure a copy of the modified work offer is submitted to Jillian in HR.

• Immediately offer modified work and provide a copy to Jillian in HR.

Corrective Actions

• What steps did you take to immediately contain the hazard? Your goal is to prevent this from happening to any other workers. Examples include: removing trip hazard, locking out equipment, stopping work etc.

• What is the root cause of the incident? Use the 5 Why's or Fishbone diagram if you need help.

• What preventative actions do you recommend?

Signoff

• Supervisor Name

• Date and time report completed

  Date