How to use the tool


Download 37.51 Kb.
NameHow to use the tool
A typeDocumentation
























Tool Type

Model Report

Last Reviewed

1, Sept 2010







Geography

All

Source


























Model Incident Investigation Report – Alberta Version

BENEFITS


Enables you to systematically capture the information you need to investigate and report incidents and identify potential problems that you can subsequently correct.

HOW TO USE THE TOOL


Immediately after the incident occurs, appoint a competent worker(s) to investigate and use the form to gather the key information about causes—both root and immediate—and injuries, illnesses and/or property damage resulting. This form comes from WorkSafe Alberta and is based on Alberta law.

ADDITIONAL RESOURCES


Community: Post a question in the discussion forum to identify other members who have dealt with this issue.

Model Incident Investigation Report – Alberta Version
Sample Incident Investigation Report

Type of Incident (as described under section 18 of the Alberta Occupational Health and Safety [OHS] Act). Check all that apply:

Serious injury

Serious incident

Minor injury

Potential for serious injury (near miss)

Property damage

Production loss

Other: ________________________________________________________________

Incident must be immediately reported to the Government of Alberta, Workplace Health and Safety, 1‐866‐415‐8690 WHS Contact Centre:

Yes No

Date/time reported (if applicable): ______________________________________________


2) Basic Information about Incident

Date and time of incident:

Location of incident:

Name of employer:




  1. Injured Workers (if any)

Name (worker #1):

Position/title:

Nature of injury:

Severity:

Fatal

More than 2 days in hospital

Medical aid

First aid

Time lost from work

Permanent disability

Name (worker #2):

Position/title:

Nature of injury:

Severity:

Fatal

More than 2 days in hospital

Medical aid

First aid

Time lost from work

Permanent disability

4) Witnesses (if any)

Were witness statements taken?

Yes (attached to report)

No

5) Circumstances/Description of Incident

Accurately describe, in chronological order, the relevant details of what happened immediately before, during, and after the incident. Attach a sketch, diagram or photographs if it will help with the description. Sketch, diagram or photographs attached?

Yes

No

6) Causes

What were the direct, indirect and root causes of the incident?


7) Corrective Actions

What can be done to prevent a similar incident from occurring in the future? Be sure to address the root causes. List the actions that have already been taken (include the date) plus any additional actions that must be taken. Indicate who is responsible for seeing the actions completed and by when.)

8) Investigation Team

Name (person #1): _______________________________________________

Name (person #2): _______________________________________________

Name (person #3): _______________________________________________

Date of investigation: _______________________________________________

9) Follow‐up

For the purpose of preventing future injuries, corrective actions must be completed in

accordance with the OHS Act, Regulation and Code.

10) Sketch, Diagram or Photos of Incident Scene




OHS Insider | Bongarde Media Company | 501 Main St. Penticton, B.C. | V2A 9A6 | 1.800.667.9300 | info@ohsinisder.com | www.ohsinisder.comc:\documents and settings\user\my documents\my dropbox\ohsi\tools\templates\logowhite.pngc:\stocklayouts\current projects\fn99804-pl\fn99804-img02.emf

Share in:

Related:

How to use the tool iconAbstract Network Administrator Tool is a tool for remote administration...

How to use the tool icon1 It is a powerful web development tool that has eveolved into a...

How to use the tool iconDtui exe: Graphical interface version of the tool Dt exe: Command-line version of the tool

How to use the tool iconDtui exe: Graphical interface version of the tool Dt exe: Command-line version of the tool

How to use the tool iconHow to use the tool

How to use the tool iconHow to use the tool

How to use the tool iconHow to use the tool

How to use the tool iconTool Version

How to use the tool icon1Peoplefluent Tool

How to use the tool iconA tool to help your community’s efforts to be




forms and shapes


When copying material provide a link © 2017
contacts
filling-form.info
search