BCTS Safety Incident Investigation Form
FILE: ARCS-01560-20 / (Year)
Is this an incident that must be reported to WorkSafeBC as per Regulation?
Yes
No
Investigation Reporting -submit completed copy to WorkSafeBC within 30 days of incident
Fatalities – Immediately contact WorkSafeBC, BCGEU President, local BCGEU office, Deputy Minister, and BC Public Service Agency.
Infectious disease exposure – copies to BC Public Service Agency at 604-775-0697.
Incident Type
Hazard
A hazard means an observation of a condition that may expose a person to a risk of
injury or occupational disease
Close Call
An undesired event that under slightly different circumstances could have resulted in
personal injury
First Aid
A minor injury requiring only first aid treatment
Medical Aid
An injury requiring treatment by a health care professional
Incident Occurred
Business Area / Field Team:
Location Description:
Occurrence date: Y/M/D
Time Occurred:
Did the incident occur on a controlled highway?
Reported Date: Y/M/D
Yes
/ No
Weather Conditions:
Program Type: choose one best descriptor
FIELD WORK
Layout
Inspection
Walking
Other (specify):
OFFICE
Warehouse
Yard
Main Building
Other (specify):
TRAVEL
Aircraft
ATV
Vehicle
Boat
Snowmobile
Other (specify)
Injured Person(s) * if applicable
Last Name
First Name
Occupation Title
Employed for less than
12 months (Y/N)
1)
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BCTS Safety Incident Investigation Form
2)
Treatment / Injury Info *if applicable
First Aid (OFA): Yes
/ No
Medical Attention: Yes
/ No
Time Loss: Yes
/ No
Injury Description (what part of the body was injured):
Witnesses * if applicable
Last Name
First Name
Occupation Title
1)
2)
Description of Incident/Accident (include the sequence of events, decisions, activities leading up to the incident):
Contributing Factors
Root Cause
Corrective and Preventative Action and/or Recommendations
Assigned to(Name and job title of the person(s) responsible for implementing the
action):
Rev.June 2015
Due Date:
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BCTS Safety Incident Investigation Form
Completion Date:
Investigation Team
Name:
Employer Rep.
Worker Rep
Participant:
Employer Rep
Worker Rep:
Participant:
Signature:
Name:
Signature:
Date Report Completed:
Action Approval/Signatures:
Supervisor’s Name:
Comments:
Signature:
Date:
Attachments:
Evidence collections will usually, but not always, include:
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Events leading to the incident;
Conditions of the work environment, tools, equipment and employees;
Witness statements (if any witnesses); and contact information;
Photos, diagrams and/or sketches;
Reports on relevant employee training;
Applicable safe work procedures; and
Emergency response actions.
Rev.June 2015
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