Peak Incident Report and Investigation Form

HSE Incident Notification
INCIDENT NOTIFICATION - Part 1

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

INCIDENT INVESTIGATION - Part 2

The investigation is to be completed by the Site Supervisor 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 investigation 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):
Work Site Name
Site Superintendent's Name:
Site Superintendent Email
example@example.com
Company (Reporting)
Location/Address Where the Incident Occurred?

Please provide address or description of the location where the incident occurred

Street Address Line 2

CityState / Province

Postal / Zip Code
Did the Incident Occur Outside?
Weather Conditions (select all that apply):
Date of Incident:

YearMonthDay
If the incident date is unknown, please enter date incident reported
Time Incident Occurred/Discovered:

Hours: Minutes Minutes

AM/PM Option
Name of Affected Individual(s)
Provide a detailed description of the incident based on facts available at the time of report.
Include relevant details such as location, lead-up to event, what you heard, saw, smelled, etc.
Did Anyone Witness the Incident?
Name of Witness(es) (if applicable)
Witness Statement
Upload Witness Statement (if document provided)

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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:

Other
External Report Ref. Info (e.g. Police Report #, WCB Report #, Utility Company Ref.)
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?
Name of First Aid Responder?
Date First Aid was Provided?

YearMonthDay
Date
Was a First Aid Report Completed?
If no, please explain below
Did the Affected Individual Seek Medical Aid from a Medical Practitioner (Doctor, Walk-in Clinic, Hospital)?
Location Medical Aid Provided by Third-Party?
(e.g. Name of Hospital, Doctors Office, etc.)
Date Medical Aid Provided by Third-Party?

YearMonthDay
Date
Vehicle Incident (VI) Notification
Type of Vehicle Incident:
Image(s) of the Scene

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Road Condition:
Road Type:
When Did the Incident Occur?
How Many Vehicles Were Involved?

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)

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)

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)

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)
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.)?
Describe ALL Equipment involved e.g. Unit #, make, model and damage etc.
Property Damage/Operational Loss
Property Damage / Loss Category:
Provide a detailed description of the incident based on facts available at the time of report.
Was the Chemical/Fuel Spill Immediately Cleaned Up?
Please Explain (if no):
List of Items Stolen:
Value of Damage(s):
Was the Damage Caused by a Third Party (e.g. Contractor, Visitor, Client, etc.)?
Name/Company:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Near Miss / Hazard ID
Near Miss Category:

Other
Road Conditions:
Incident Hazard Identification
Select the Type of Hazard(s) that may have contributed to the incident:
Is this a Newly Identified Hazard?
Describe the 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?
Please describe any Unsafe Acts:
e.g. improper work technique, safety rule violation, guards not used, failure to secure
Were there any Unsafe Conditions that may have contributed to the incident?
Please describe any Unsafe Conditions:
e.g. congested work areas, defective tools/equipment, poor housekeeping, slippery conditions
Were there any System Deficiencies that may have contributed to the incident?
Please describe any System Deficiencies that may have contributed to the incident:
e.g. hazards not identified, improper maintenance, inadequate equipment, inadequate job planning, supervision, insufficient worker training
Have any Immediate Corrective Actions been taken to prevent reoccurrence?
Immediate Corrective Actions:
Photo Upload:

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Select Action

Rows	Vehicle 1
Driver Name
Registered Owner
Contact info (Phone, Email)
Unit#/License Plate
Year/Make/Model

Rows	Vehicle 2
Driver Name
Registered Owner
Contact Info (Phone, Email)
Unit#/License Plate
Year/Make/Model

Rows	Vehicle 3
Driver Name
Registered Owner
Contact Info (Phone, Email)
Unit#/License Plate
Year/Make/Model

Rows	Vehicle 4
Driver Name
Registered Owner
Contact Info (Phone, Email)
Unit#/License Plate
Year/Make/Model

Rows	SEVERE Death or permanent disabling injury/illness; extended loss of production, irreparable environmental destruction; or damage/loss greater than $100k	HIGH Reportable occupational injury/illness; major quality deviation/loss of production; reportable environmental release; or damage/loss ranging from $50k to $100k	MEDIUM Non-reportable injury/ illness; moderate disruption to production; non-reportable environmental release; or damage/loss ranging from $5k to $50k	MINOR First aid injury/illness; minimal impact to production; negligible environmental release; or damage/loss less than $5k
Severity Potential severity level if incident were to occur under slightly different circumstances

Rows	VERY LIKELY Occurrence is imminent; probably to occur multiple times per year	LIKELY Probable to occur at least once per year; has occurred in the past	POSSIBLE Probable to occur once every 10 years; has been observed in similar circumstances	UNLIKELY Not probable; conceivable to occur at some point
Likelihood - How likely is the incident to reoccur if no corrective actions are implemented

Rows	Daily	Weekly	Monthly	Annually
Frequency of Exposure

Initial Incident Notification Sign Off
Incident Notification Submitted by:
First and Last Name
Incident Notifier Email
example@example.com
Job Title:
Title of reporting employee (named above)
Signature:
Date

MonthDayYear
mm-dd-yyyy
Incident Investigation Sign Off
Incident Investigation Submitted by:
First and Last Name
Job Title:
Title of reporting employee (named above)
Signature:
Date:

YearMonthDay
mm-dd-yyyy
Email Sender

Manager Review
Manager Name:
First and Last Name
Manager Email:
example@example.com
Injury/Illness Type:
Vehicle Incident (VI) Character:
Classification of Vehicle Incident:
Preventable Vehicle Incident (PVI) Grading:

Total Restricted/Modified Duty Days:
Total Lost Days:
Additional Corrective Actions Assigned by Manager:
I confirm the Violence & Harrassment Prevention Plans were reviewed as per our H&S program requirements.
Manager Notes:
Manager Signature:
Date:

MonthDayYear
mm-dd-yyyy
Should be Empty:

Rows	# of Days
January
February
March
April
May
June
July
August
September
October
November
December

Rows	# of Days
January
February
March
April
May
June
July
August
September
October
November
December

HSE Incident Notification

Injury/Illness Notification

Vehicle Incident (VI) Notification

Property Damage/Operational Loss

Near Miss / Hazard ID

Incident Investigation

Initial Incident Notification Sign Off

Incident Investigation Sign Off

Manager Review