RSCL | Accident / Incident & Occupational Disease

Investigation Report
Send copy to: a) Occupational Health & Safety Committee
b) Program Manager

Date of Report

Last name of injured (or ill) First name Employee# Telephone

person

□ Male □ Female
Program’s name Location

Year’s service Time on present job Occupation Hours worked in previous

24-hour period

Accident location – on site or Date of accident Time

premises

Accident Category

(please check applicable box) □ Injury or illness □ Equipment malfunction □ Motor vehicle □ Property Damage □ Fire
□ Potential for causing serious injury or accident
□ Other, please specify _____________________________________________________________________________
Severity of injury or illness □ No injury □ Potential for causing serious injury or accident
(please check applicable box) □ First Aid only □ Medical treatment □ Disabling □ Fatal Time Loss □ Yes □ No
Name of injury or illness

Name of witness:

Description of incident or employee’s account of illness (please use a separate sheet if necessary) What happened before,
during, after incident?

Was written safe work procedure or training Was it adequate?

established and/or available?

□ Yes □ No □
Yes □
No
Please describe the results of incident or illness (property damage, type of injury, nature of illness or disease)

…2 (over)

Richmond Society for Community Living Page 1 of 2 OHS_Accident_Investigation_Report_Form.doc

 What was the basic cause (and contributory cause(s) if any):
Please explain fully unsafe act, condition or personal factor (please use reverse side for additional comments)

What related training has the employee had?

Corrective measures taken and/or recommended: Corrective action referred to:

To be completed by:

Corrective Action Completed:

Additional comments or observations

(Where applicable, please give details of makes and models of machines, equipment, tools, structures, etc.,
involved in this accident. Use separate sheet if necessary).

Name and occupations of persons who investigated Comments:

accident

Signature of OH&S employee representative/union member Signature of supervisor

Signature of employee consulted Date

Richmond Society for Community Living Page 2 of 2 OHS_Accident_Investigation_Report_Form.doc