HEALTH AND SAFETY INCIDENT

REPORT FORM

INSTRUCTIONS Fill out this form immediately after a work-related incident and submit it to:

REPORTED BY	DEPARTMENT
PHONE	EMAIL

INCIDENT DETAILS

LOCATION	DATE OF INCIDENT	TIME
INCIDENT TYPE select one
ACCIDENT	INCIDENT	NEAR MISS
VIOLENCE	ILL HEALTH	SAFETY
INCIDENT DESCRIPTION Report any details that may have contributed to the incident. Attach additional information as necessary.
OUTCOME DESCRIPTION Detail all harm / health effects / damage.
CORRECTIVE MEASURES Describe corrective measures taken to address immediate hazards related to the incident.

INDIVIDUAL AFFECTED

NAME	EMPLOYEE ID	DATE OF BIRTH
POSITION job title or designation, i.e., visitor, contractor, etc.
WORK PHONE	WORK EMAIL
PERSONAL PHONE	PERSONAL EMAIL
HOME ADDRESS
EMPLOYER NAME if individual affected is not an employee	EMPLOYER PHONE
EMPLOYER ADDRESS

WITNESS DETAILS

NAME	CONTACT INFORMATION

FIRST AID

FIRST AID ADMINISTERED?

YES	ADMINISTERED BY
NO	CONTACT INFORMATION
N/A	TIME OF ADMINSTRATION
DETAILS OF FIRST AID ADMINISTERED

POST INCIDENT

WHERE DID THE INDIVIDUAL AFFECTED GO NEXT? select one
TO THE HOSPITAL	HOME	RETURNED TO WORK	OTHER
EXPLANATION / FURTHER DETAILS IF OTHER

Was a member of the joint health and safety committee notified of the incident?

YES	INDIVIDUAL CONTACTED
NO	CONTACT INFORMATION

ADDITIONAL NOTES

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