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Workplace accident investigation forms

Oct 16, 2008 · Accident Investigation East Carolina University Environmental Health & Safety 210 East Fourth Street (252) 328-6166 ….
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Aug 30, 2014 · Workplace accident investigation Checklist. workplace safety rules, such as those regulated by the Occupational Safety and Health Administration, help ...
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Exact Location Give the exact location in the work area where the injury/accident occurred. ... By Name of the person completing the accident investigation Form.
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Internal accident investigation Form This form is an internal accident investigation document to facilitate, change, and improve the work environment
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Title: accident investigation FORM Author: IBM Last modified by: Administrator Created Date: 5/16/2003 7:41:00 PM Company: Texas Workers' Compensation …
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Accident investigation forms accident investigation forms/statements should be filled out by the injured employee, supervisor and any witness to the accident.
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The Supervisor's accident investigation and Report form does not replace the First Report of Injury or Illness form.
Supervisor's Accident Investigation & Report Form - Idaho ...
Prevention & investigation Course Objectives Understand the need to investigate Know what to investigate Determine the causes of accidents Identify the methods of ...
Accident Investigation Forms - St. Mary's College Of …
Oct 16, 2008 · Accident investigation East Carolina University Environmental Health & Safety 210 East Fourth Street (252) 328-6166 …
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March 1, 2007
UPDATED: July 2012

The purpose of this procedure is to identify the duties, roles and responsibilities of workplace parties so that an effective and immediate accident/incident investigation and reporting process is in place.This will include identifying all contributing factors of the accident/incidents and hazardous situations and making the necessary recommendations to prevent the accident/incident from recurring.



Review annually reports of the following injury/incident types to determine any investigation needs:

o First Aid o Health Care o Near Miss


o First Aid - When an employee, as a result of an accident in the workplace receives on-site first aid assistance.Includes cleaning minor cuts, scrapes or scratches; treating a minor burn, applying bandages and/or dressings, cold compress, cold pack, ice bag, and splints.o Health Care An injury that results in attention received from a recognized health care provider but that does not result in time away from scheduled work or a wage loss o Near Miss An event that under different circumstances could have resulted in physical harm to an individual or damage to the environment, equipment, property and/or material


The following categories of accident/incidents require an immediate investigation as they may produce a loss to people, equipment, material and environment: o Fatality An injury that results in loss of life o Critical Injury As defined in the Ontario Regulation 834/90 it is a critical injury if the injury places life in jeopardy; produces unconsciousness; results in substantial loss of blood; involves the fracture of a leg, or arm but not a finger or toe; involves the amputation of a leg, arm, hand, or foot but not a finger or toe; consists of burns to a major portion of the body; or
causes the loss of sight in an eye.

o Lost Time A work related injury that results in the injured employee missing scheduled time from work resulting in a wage loss o Property Damage - When there is significant property damage, a value of $250 is suggested as a general guideline to be used by a supervisor, although other factors could impact on the need and level of investigation and reporting o Occupational Illness A condition that results from exposure in a workplace to a physical, chemical or biological agent that normal physiological mechanisms are affected and the health of the worker is impaired o Environmental Release An accidental discharge of a physical, biological or chemical substance into the workplace and/or community o Fire/Explosion An event where undesired combustion occurs

workplace accident investigation forms

The results and corrective action taken for the accident/incidents will be communicated to the employees in a number of ways:

Minutes of the health and safety committee meetings Postings on the safety bulletin boards Follow up on Action Plan completed by the supervisor/leader to affected individuals

Notification requirements are the responsibility of Occupational Health and Safety(as outlined below) to notify the following:

External Ministry of Labour (MoL) - must be notified immediately by phone, of any fatalities or critical injuries, with this to be followed by a written investigation report within 48 hours.

Ministry of Labour (MoL) - Fire and Explosion immediately if it results in an injury.

Ministry of Environment (MoE) Chemical releases immediately. Federal - Dangerous goods (spills) Immediately Workplace Safety & Insurance Board (WSIB) within 3 days or upon first becoming aware of, any accident that causes injury which results in Health Care or Lost Time


Internal Joint Occupational Health and Safety Committee Wellness Information Coordinator, Rehabilitation Services - when an accident causes injury that results in Health Care or Lost Time.

An Employees Report of Accidental Injury or Industrial Disease (FORM 7) must/will be sent to the Workplace Safety and Insurance Board (WSIB) within 3 days of the accident or upon first becoming aware by the Wellness Information Coordinator Corporate Insurance Administrator, Human Resources property, vehicle and/or equipment damage

4.ROLES & (Investigator) Responsibilities The supervisor in the area where it happened investigates the accident/incident and completes the investigation report within 24 hours of the accident/incident or hazardous situation.Fax the completed Accident/Incident Investigation Report to 519-661-2079 (ext 82079 on campus). In the case of personal injury the supervisor ensures that the injured employee(s) receive immediate and appropriate first aid and/or health care.

Reports those injuries that result in critical injury to Occupational Health & Safety (OHS) immediately by calling ext 82198.During non-business hours the supervisor should call Campus Community Police Services at ext 83300 or 911 from a campus phone. In conducting the accident/incident investigation and completing the Accident/Incident Investigation Report, the supervisor must ensure the following has been completed:

o Assessment of the Scene i) Inspection of the site, equipment, material that were involved in the accident/incident ii) Site must be secured especially in the case of a critical injury iii) Use of photographs, sketches, drawings of the accident/incident scene indicating sizes, distances, and weights of objects as appropriate

o Interviewing i) Interview employee(s) involved ii) Interview any eyewitnesses iii) Interview outside experts if applicable i.e.

suppliers, equipment designers iv) Interviews must be documented v) Interviews should be conducted as soon as possible vi) Interviews should be conducted one-on-one in a quiet place

o Identifying the contribu
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