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ACCIDENT INVESTIGATION REPORT

Employee Information

Last Name: First Name: Middle Initial(s):

Work Phone Number: Home Phone Number:

Employment Information

Site Location: Employee #:

Date of Hire: Language (If other than English):

Occupation / Job at Time of Incident: Length of Time in Occupation / Job:

______ Years ______ Months ______ Days

Type of Employment (check all which apply): Full Time Part Time Hourly Salary Casual

Contractor Name of Company:

Details of Investigation

Site: Department: Exact Location of Incident on the Premises:

Immediate Supervisor:

Incident Date: Month: Day: Year: Time: am [ ] pm [ ]

Date Reported: Month: Day: Year: Time: am [ ] pm [ ]

Date of Investigation: Month: Day: Year: Time: am [ ] pm [ ]

TYPE: Incident Near Miss Property Damage Spill / Release

WCB Report required: Yes No WCB Report Completed: Yes No

No Lost Time Lost

INJURY / ILLNESS: None First Aid Medical Aid Hospital Fatality
Time

Part of Body Injured: (Provide a detailed description and specify left or right, front or back)

Has the injured worker had a previous similar injury? Yes No (If yes, describe in detail)
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Medical Treatment Information

Name of First Aid Attendant: Injury Recorded in First Aid Log? Yes No

Type of First Aid Administered:

Clinic / Hospital sent to:

Attending Physician / Paramedic (if known):

Attending Police Officer (if known):

(B) – Property

Property Damaged: Estimated Cost of Damage: $

Description of Damaged Property:

(C) – Witness Information

Number of Witnesses: _____ ATTACH WITNESS STATEMENT(S) FOR EACH WITNESS

Investigation Information

Type of Incident: Assault Break Caught In Caught On Caught Between Cut On Exposure
Fall Over Exertion Strain Struck By Struck Against Trip Other (specify):

Contact With: Cold Heat Electricity Fire Noise Pressure Equipment

Caustic Chemical (specify):_________________________ Toxic Chemical (specify):______________________
Other (specify):______________________________

Describe in detail the SEQUENCE OF EVENTS leading up to the incident. (ie. Where the incident occurred; what the
employee was doing at the time; the size, type and weight of equipment or materials involved; weather conditions, etc.).
Use additional pages if required and provide diagrams, photographs and reports.

Diagram / Photographs attached Yes No

ALL EVIDENCE / INFORMATION GATHERED FOR INVESTIGATION TEAM ONLY
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Identify all UNSAFE ACTS which contributed to the incident: (check off as many as necessary)

Operating Without Authority Horseplay Servicing Operating Equipment

Unsafe Loading / Unloading Inadequate Lighting Using Defective Tools

Unsafe Mixing / Combining Working at Unsafe Speed Using Defective Equipment

Failure to Wear Proper PPE Distracting Working on Moving Equipment

Failure to Warn Properly Teasing Improper Lifting

Failure to Secure Properly Harassment Unfit for Duty (possible impairment)

Unsafe Position or Posture Hazardous Personal Attire Making Safety Device Inoperable

Other (specify):

Identify all UNSAFE CONDITIONS which contributed to the incident: (check off as many as necessary)

Inadequate Guards / Barriers Gases Hazardous Environmental Conditions

Improper or Inadequate PPE Dusts Extreme Weather Conditions

Inadequate Lighting Fumes Extreme Temperature(s)

Unsafe Job Design Vapours Noise Exposure

Congested Work Area Smoke Unsafe Mobile Equipment

Inadequate Warning Systems Explosion Hazard Defective Tools or Equipment

Poor Housekeeping Fire Hazard Defective Materials

Other (specify):
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Identify all INDIRECT CAUSES which contributed to the incident: (check off as many as necessary)

Personal Factors Job Factors

Inadequate Physical Capability Inadequate Leadership or Supervision

Abuse or Misuse of Equipment Inadequate Engineering Controls

Physical Stress Inadequate Purchasing

Mental Stress Inadequate Maintenance (scheduled or preventative)

Lack of Knowledge Inadequate Tools or Equipment

Lack of Skill Inadequate Work Standards

Improper Motivation Wear and Tear

Identify all ROOT CAUSES which contributed to the incident: (check off as many as necessary)

Management Commitment & Administration Emergency Preparedness and Response

Leadership Training Company Safety Rules and Work Permitting

Planned Inspections Worker Knowledge & Skill Training

Preventive Maintenance Personal Protective Equipment (PPE)

Hazard Identification Personal or Group Communications

Safe Work Practices and/or Procedures Hygiene and Sanitation

Inadequate Previous Incident Investigation Hiring & Placement Standards

Purchasing Controls Other(s);

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(E) - Prevention
(Number those actions required to Prevent Recurrence of a similar incident, 1 being most critical in order of priority)

Training / Retraining of Involved Worker(s) Improve Safety Inspection Process

Job Procedure / Design Changes Reassignment of Involved Worker

Equipment Repair or Replacement Liaison with Manufacture of Equipment / Tool

Perform in-depth Hazard Identification

Facilities Layout Review and Redesign
and Analysis

Improved Hazard Controls

Installation of Safety Guards / Barriers
(engineering / admin. / PPE)

Supervisory Communication Other (specify):

Describe Action(s) Taken to Prevent Recurrence (short term and long term)

Assignment of Action Item(s)

Action item; Responsible; Date of completion; Sign-off;

Action item; Responsible; Date of completion; Sign-off;

Action item; Responsible; Date of completion; Sign-off;

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Investigation Team (First & Last Names)

Lead Investigator Position & Department

Investigator Position & Department

Investigator Position & Department

Lead Investigator Comments:

Lead Investigator Name (print): Signature: Date:

Involved Worker(s) Comments

Employee Statement Attached

Employee Name (print): Signature: Date:

Additional Management Comments

Manager Name (print): Signature: Date:

Investigation Number:

Send Completed Report To:

 Department Manager
 Internal Health & Safety Advisor
[email protected]