Investigation Reporting Form

Investigation Reporting Form

Quality Assurance Coordinator to review all incidents and do an investigation. Please provide the following information.
Employee Information
Staff's Name

First NameLast Name
Job Title
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Supervisor Name
Manager Name
Incident Information
Who was involved in the Incident?

First NameLast Name
Date & Time when Incident occurred:

MonthDayYear
Date
Hour MinutesAM/PM Option
What Type of Incident is this?

Non-Critical IncidentCritical IncidentOther
Incident Location (Please provide specific details):
Please provided address / specific details
Description of Incident
Describe in detail what happened and any contributing factors (i.e. equipment or tools involved), and including the type of injury and how it occured occurred (if applicable). Be clear & specific.
Was there anyone else involved in the incident?
List Names and Contact Information of the involved staff member, the direct manager, and any witnesses, etc.
Initial Response & Treatment
Was first aid provided to anyone involved in the incident?

YesNoN/A
Details of First Aid Provided (if applicable):
Describe the treatment given on-site. Please note who provided the first aid, what first aid was provided, whom first aid was provided to, and the first aid provider's contact information.
Medical Treatment Required?

YesNoOther
Type of Medical Treatment Sought (if applicable):
For example: Emergency Room, Clinic, etc.
Were First Responders Called?

YesNoOther
Further Comments
File Upload

Cancelof
Reporting and Investigation
Scheduled Meeting Date

MonthDayYear
Date
Reported To
Manager/Supervisor's Full Name
Conducted By:

First NameLast Name
Job Title:

Quality Assurance CoordinatorManagerDirectorOther
Findings from Investigation
Summarize the key findings, including the root cause of the incident: the staff member's explanation, and any mitigating circumstances.
Can any of the following be attributed:
Was there a breach of policy?

YesNoOther
Would any policies need to be revised as a result of this incident?

YesNoPotentially
WorkSafe Claim Filed?

YesNo
WorkSafe Claim Number (if applicable)
Date WorkSafeBC Notified:

MonthDayYear
Deadline for Filing Report with WorkSafe BC (Within three business days or the injury or becoming aware of injury)
Disciplinary/Corrective Actions

If Applicable
Disciplinary Actions?

YesNoOther
Was HR notified?

YesNoOther
Corrective Actions Implemented (If Applicable):
Were any hazardous conditions corrected or addressed after the incident?

YesNo
If yes, please describe (the steps taken):
Additional Comments:
Acknowledgement*

I hereby certify that the information provided above is true, accurate, and complete to the best of my knowledge.
Should be Empty:

Investigation Reporting Form

Employee Information

Incident Information

Initial Response & Treatment

Reporting and Investigation

Disciplinary/Corrective Actions