IncidentsReport-Injury2020

Injury or Incident Investigation Report
Type of Incident *

Serious incident First aid Medical aid Serious Injury Potentially serious incident Property damage Production loss
Required immediate reporting to Government of Alberta, Occupational Health and Safety 1-866-415-8690 *

Yes No
Date and time reported *

Month Day Year
Date Hour Minutes AM/PM Option
Worker job title *
Date of incident *

Month Day Year
Date
Incident reported to *

First aider Supervisor Another worker Health & safety committee member Health & safety representative
Location of incident *
Witness job title *
Were statements taken *

YES (attached) NO
Witness job title *
Were statements taken *

NO YES (attached)
Witness job title *
Were statements taken *

NO YES (attached)
Report reviewed by: *

Supervisor health & safety committee member health & safety representative Employer Prime contractor
Sketch/diagram/photos attached *

YES NO
Description of the incident: *
Direct cause (action, event or force that is the immediate or primary agent which led to the incident) *
Indirect cause (did not directly cause the incident but contributed to the outcome) *
Root cause (the basic conditions that allowed each of the direct/indirect causes to occur): *
Corrective action: *
Assigned *
Completed on: *

Month Day Year
Date
Witness job title *
Date of incident *

Month Day Year
Date
Date of statement *

Month Day Year
Date
Name of employer *
Where were you when the incident occurred? *
Describe what you saw heard, smelled, felt or tasted immediately before the incident? *
Describe what you saw heard, smelled, felt or tasted immediately after the incident? *
add photo of the sketch incident scene to help describe your observations or show where you were.
Any additional comments about the incident? *
Date of Employee reporting Incident

Month Day Year
Date
Signature of employee

Clear
Supervisor Signature

Clear
Date

Month Day Year
Date
Should be Empty: