Title Page

  • Conducted on

  • Prepared by

  • Location
  • What type of incident is this?

  • 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

Incident Information

  • Incident Location

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

  • Date and time of incident

  • Date and time reported to supervisor

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

  • If not, explain why?

  • Incident description (what happened?)

  • Were there any witnesses to the incident?

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

  • Were any Dortec Safety Rules broken?

  • 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?

  • Injury description (be detailed as possible)

  • Did the worker receive first aid?

  • Who provided first aid?

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

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

  • When did they receive medical attention?

  • Is the worker able to continue their regular duties?

  • Was modified work offered?

  • 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?


  • Supervisor Name

  • Date and time report completed

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