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 Name
Last Name
Job Title
Please Select
Community Support Worker
Case Manager
Program Supervisor
Program Manager
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 Name
Last Name
Date & Time when Incident occurred:
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
What Type of Incident is this?
Non-Critical Incident
Critical Incident
Other
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?
Yes
No
N/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?
Yes
No
Other
Type of Medical Treatment Sought (if applicable):
For example: Emergency Room, Clinic, etc.
Were First Responders Called?
Yes
No
Other
Further Comments
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Reporting and Investigation
Scheduled Meeting Date
-
Month
-
Day
Year
Date
Reported To
Manager/Supervisor's Full Name
Conducted By:
First Name
Last Name
Job Title:
Quality Assurance Coordinator
Manager
Director
Other
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:
Please Select
Negligence
Misunderstanding
Unforeseen Circumstances
Other
Was there a breach of policy?
Yes
No
Other
Would any policies need to be revised as a result of this incident?
Yes
No
Potentially
WorkSafe Claim Filed?
Yes
No
WorkSafe Claim Number (if applicable)
Date WorkSafeBC Notified:
-
Month
-
Day
Year
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?
Yes
No
Other
Was HR notified?
Yes
No
Other
Corrective Actions Implemented (If Applicable):
Were any hazardous conditions corrected or addressed after the incident?
Yes
No
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.
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