• HSE Incident Notification

  • INCIDENT NOTIFICATION - Part 1

    The reporting worker must fill out and complete the Incident Notification which is submitted to the HSR/Committee & a copy to the reporting worker. The HSR/Committee will review the information provided to determine if further investigation is required. 

    INCIDENT INVESTIGATION - Part 2

    The investigation is to be completed by the HSR/Committee and/or designee in cooperation with any additional persons (i.e. H&S Dept, HS Committee, affected worker, etc.) to update and/or confirm initially reported information and close out or assign additional corrective action to prevent future loss. 

    INCIDENT REVIEW - Part 3

    The completed inveistgation is sent to the responsible Manager for review and additional comments and corrective actions as necessary. 

     *Please remember to take photos of the scene, equipment, damage, etc., and gather statements from affected workers whenever it is reasonably practicable to do so*

  • Incident Type(s):*
  • Did the Incident Occur Outside?*
  • Weather Conditions (select all that apply):
  • Date of Incident:*
     - -
    4 digit year, 2 digit month, 2 digit day
  • Time Incident Occurred/Discovered:*
  • Name of Affected Individual(s)
  • Did Anyone Witness the Incident?*
  • Name of Witness(es) (if applicable)
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  • Was Anyone Else Directly Involved or Affected by this Incident (i.e. contractors, visitors, public, etc.)?*
  • Names of Individuals Directly Involved or Affected:
  • Have External Authorities and/or Emergency Services Been Contacted/Involved?*
  • Scene Response Included:*

  • Injury/Illness Notification

  • Nature of Injury/Illness:*
  • Identify Affected Area(s):*
  • What Side of the Body Has Been Affected?*
  • Was First Aid Provided at Site?*
  • Date First Aid was Provided?*
     - -
    4 digit year, 2 digit month, 2 digit day
  • Was a First Aid Report Completed?*
  • Did the Affected Individual Seek Medical Aid from a Medical Practitioner (Doctor, Walk-in Clinic, Hospital)?*
  • Date Medical Aid Provided by Third-Party?*
     - -
    4 digit year, 2 digit month, 2 digit day

  • Vehicle Incident (VI) Notification

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  • When Did the Incident Occur?*
  • 1. Vehicle*
    Rows
  • Was the driver of Vehicle 1 hurt as a result of the incident?*
  • Select the areas damaged on Vehicle 1 as per the diagram shown below:*
  • Take Photo of Vehicle 1
  • Take Photo of Vehicle 1 (additional)
  • 2. Vehicle*
    Rows
  • Was the driver of Vehicle 2 hurt as a result of the incident?*
  • Select the areas damaged on Vehicle 2 as per the diagram shown below:*
  • Take Photo of Vehicle 2
  • Take Photo of Vehicle 2 (additional)
  • 3. Vehicle*
    Rows
  • Was the driver of Vehicle 3 hurt as a result of the incident?*
  • Select the areas damaged on Vehicle 3 as per the diagram shown below:*
  • Take Photo of Vehicle 3
  • Take Photo of Vehicle 3 (additional)
  • 4. Vehicle*
    Rows
  • Was the driver of Vehicle 4 hurt as a result of the incident?*
  • Select the areas damaged on Vehicle 4 as per the diagram shown below:*
  • Take Photo of Vehicle 4
  • Take Photo of Vehicle 4 (additional)
  • Image field 84
  • Was a Third-Party Injured as a Result of the Incident? (e.g. Pedestrians, Public)*
  • Injured Third-Party Information:*
  • Was Anyone Else Directly Involved or Affected by this Incident (i.e. contractors, visitors, public, etc.)?*
  • Names of Individuals Directly Involved or Affected:*
  • Was any Equipment Involved or Affected by this Incident (i.e. contractors, visitors, public, etc.)?*

  • Property Damage/Operational Loss

  • Property Damage / Loss Category:*
  • Was the Chemical/Fuel Spill Immediately Cleaned Up?*
  • List of Items Stolen:*
  • Value of Damage(s):*
  • Was the Damage Caused by a Third Party (e.g. Contractor, Visitor, Client, etc.)?*
  • Format: (000) 000-0000.

  • Near Miss / Hazard ID

  • Near Miss Category:*

  • Incident Hazard Identification

  • Select the Type of Hazard(s) that may have contributed to the incident:
  • Is this a Newly Identified Hazard?*

  • Identify ALL factors that may have contributed to the incident.

  • Were there any Unsafe Acts that may have contributed to the incident?*
  • Were there any Unsafe Conditions that may have contributed to the incident?*
  • Were there any System Deficiencies that may have contributed to the incident?*
  • Have any Immediate Corrective Actions been taken to prevent reoccurrence?*
  • Immediate Corrective Actions:*
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  • Select Action*

  • Incident Investigation

  • You must submit the information in this section to your designated reporting person within 48 hours from the date of occurence OR from the date of first report.

    Investigations should be completed as soon as reasonably practicable. Begin collecting information immediately.

  • Date of Investigation:*
     - -
    4 digit year, 2 digit month, 2 digit day
  • Participants

  • Affected employee statement of events and factors that may have contributed to the incident:

     

  • WCB or Injured Worker Information
  • Was there any Modified/Restricted Duty(s) required?*
  • Was there time lost beyond the day of the incident?*

  • Root Cause Analysis

    For every incident, a root cause analysis helps us identify system deficiencies that may have contributed to the event.

    The responsible manager and/or HS Representative will review the information collected during the investigation to determine the causal factors related to the incident.

     

    A corrective action should be assigned to address each causal factor identfied during the investigation. 

  • Direct Causes (Worker Level)

  • Substandard Practices
  • Substandard Conditions

  • Basic Causes (Supervisor Level)

  • Lack of knowledge / Skill related to...
  • Improper Motivation related to...
  • Inadequate Supervision related to...
  • Inadequate Work Standards related to...

  • Root Causes (Management Level)

  • Management failure to establish or maintain standards for...*
  • Select the level of Severity associated with this incident:*
    Rows
  • Select the Likelihood of the Incident Reoccurring if Uncontrolled:*
    Rows
  • Frequency the Task/Operation is Performed Under Normal Circumstances:*
    Rows

  • The total risk factor (TRF), is based upon the severity, liklihood for recurrence and how often the situation arises.

    On a scale of 3 - 12, with 12 being the highest risk factor and most serious.

    3-5: A minor incident with low exposure and liklihood of recurrence, requires apporpriate corrective actions within a fixed time period.

    6-8: An incident with medium risk, requires modification to processes and corrective action within a week

    9-12: An incident with serious outcomes and liklihood of recurrents, requires immediate attention and corrective actions.  

  • List of Corrective Actions:*
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  • IMPORTANT - In the event an incident is ongoing at the time of the investigation, be sure to maintain a record of corrective measures implemented, discussions with affected personnel and any other pertinent information as applicable to the event.

  • Initial Incident Notification Sign Off

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Incident Investigation Sign Off

  • Date:*
     - -
    4 digit year, 2 digit month, 2 digit day

  • Manager Review

  • Classification of Vehicle Incident:
  • Preventable Vehicle Incident (PVI) Grading:
  • Modified/Restricted Duty(s) Summary:*
    Rows
  • Lost Time Day(s) Summary:*
    Rows
  • Additional Corrective Actions Assigned by Manager:
  • Manager Notes:
  • Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: