INCIDENT INVESTIGATION REPORT
DEPARTMENT:
LOCATION OF INCIDENT:
DATE OF INCIDENT:
TIME:
DATE REPORTED:
TIME:
INJURY OR ILLNESS
OTHER INCIDENTS
INJURED’S NAME:
OCCUPATION:
AREA OF INJURY/ILLNESS:
NATURE OF INJURY/ILLNESS:
TIME ON TASK:
PERSON REPORTING INCIDENT:
OBJECT/EQUIPMENT/SUBSTANCE
INVOLVED:
PROPERTY DAMAGE TO:
NATURE OF DAMAGE:
PERSON WITH MOST CONTROL OF
OCCUPATION:
PROPERTY DAMAGE
TYPE OF CONTACT:
STRUCK AGAINST
STRUCK BY
CAUGHT IN/ON
SLIP/TRIP
FALL ON SAME LEVEL
FALL TO BELOW
COST
OVEREXERTION
REPETITION
BODILY REACTION
ESTIMATED
ACTUAL
CONTACT WITH:
ELECTRICITY
HEAT/COLD
NOISE
TOXIC SUBSTANCE
CORROSIVES
LASER, RADIATION
RISK
EVALUATION OF LOSS POTENTIAL IF NOT CORRECTED:
SEVERITY:
SEVERE
SERIOUS
MINIMAL
PROBABILITY:
HIGH
DESCRIPTION
DESCRIBE HOW THE EVENT OCCURRED:
IS THERE A WRITTEN SAFE WORK PROCEDURE OR JOB HAZARD ANALYSIS FOR THIS JOB/TASK?
YES
NO
HAS THIS WORKER RECEIVED TRAINING RELEVANT TO THE ACTIVITY INVOLVED?
YES
NO
WITNESSES TO THE INCIDENT (NAME AND CONTACT NUMBER):
MEDIUM
LOW
IMMEDIATE CAUSES
ROOT CAUSES
WHAT SUBSTANDARD ACTIONS/CONDITIONS CAUSED THE
INCIDENT? CHECK BELOW, EXPLAIN HERE:
WHAT PERSONAL OR JOB FACTORS CAUSED THE INCIDENT?
CHECK BELOW, EXPLAIN HERE:
IMMEDIATE CAUSES (CHECK ALL THAT APPLY)
ROOT CAUSES (CHECK ALL THAT APPLY)
Substandard Actions
Operating equipment without authority
Failure to warn
Failure to secure
Operating at improper speed
Making safety devices inoperable
Removing safety devices
Using defective equipment
Using equipment improperly
Failure to use personal protective equipment
Improper loading, placing, mixing
Improper lifting
Improper position/posture for task
Servicing equipment in operation
Horseplay
Under influence of alcohol and/or drugs
Other action _______________________
Personal Factors
Inadequate ability
Lack of knowledge of the task
Lack of skill
Stress/rushing
Improper motivation
Substandard Conditions
Operating equipment without authority
Inadequate/improper protective equipment
Defective tools, equipment or materials
Congested workspace or restricted action
Inadequate warning system
Fire and explosion hazards
Poor housekeeping
Hazardous physical environment
Excessive noise
Radiation, laser, X-ray exposure
Exposure to biological hazard
Inadequate or excessive illumination
Inadequate ventilation
Heat/cold exposure
Repetitive tasks
Other condition _____________________
Job Factors
Inadequate leadership/supervision
Inadequate engineering
Inadequate purchasing
Inadequate maintenance
Inadequate tools/equipment/materials
Inadequate work standard/procedure
Wear and tear
Abuse or misuse
CORRECTIVE ACTIONS (CHECK ALL THAT APPLY)
Actions to improve design/method
Consult with manufacturer
Remove hazard
Consult with JHSC
Consult with Ministry of Labour
Correction of congested area
Action to improve inspection
Develop safe work procedure
DESCRIPTION OF ACTION(S) TAKEN:
Improve housekeeping procedure
Grounds Maintenance
Inform all department supervision
Provide training
Install guard or safety device
Order Job Hazard Analysis
Provide appropriate PPE
Review policies/procedures
Provide proper ventilation
Discipline of person involved
Re-instruction of person(s) involved
Ergonomic assessment
Repair equipment/facilities
Corrective Action not required
Replace equipment/tools
Other
CORRECTED (CHECK BOX) PLANNED (CHECK BOX)
DATE (DD/MM/YY)
1.
2.
3.
4.
5.
SIGNATURE AND APPROVALS
Name of person completing report:
Signature:
Date:
Phone Number/ Extension:
Manager/department head:
Signature:
Date:
Phone Number/Extension:
Cc: Dept. head/chair, Health & Safety Coordinator
Retention: 2 years in Department
Disposition: Secure Destruction
Safety Office June 2012 (HS60)