Fillable Incident Investigation Report - Fanshawe College printable pdf download

GUIDE TO COMPLETING THE INCIDENT INVESTIGATION REPORT FORM

Definitions

Incident:

an unplanned event that results in, or could result in, an injury or fatality, or damage/destruction of

equipment, property or the environment.

Incidents may result in one or more of the following:

•

Near-Miss: an incident that does not result in an injury

•

First Aid: treatment such as ice packs, bandages or eyewash flushing, etc.

•

Medical Aid: treatment or examination by a physician, dentist, chiropractor, physiotherapist, emergency

room attendant or similar health care practitioner

•

Lost Time: unable to attend the next regularly scheduled shift of work

•

Critical Injury: an injury that results in a broken bone, significant loss of blood, loss of sight, an

amputation, burns to a major part of the body, unconsciousness (not due to personal health),

or places life in jeopardy

This form can be completed electronically and must be sent to your Manager/Chair or College Contact

ASAP, so that it can be reviewed and sent to Environment, Health and Safety Services

(incident@fanshawec.ca) within 24 hours of the incident.

All slips and falls should be reported immediately to the Security Control Centre at 519-452-4400.

If your injury is identified as a critical injury you must immediately report the injury to your

Manager/Chair.

Instructions for Person Involved in the Incident:

•

Check the appropriate box under the Incident Classification section

•

Continue with relevant sections, as outlined below:

•

Employees complete Sections A, B, C, F, G, I

•

Students complete Sections A, B, D, F, G, I

•

Visitors and Contractors complete Sections A, B, E, F, G, I

•

If an incident later escalates into a medical aid or lost time, you must notify your Manager/Chair or College

contact of this change.

•

Incidents should not be reported to Team Leaders/Program Coordinators as they are not supervisors

Instructions for Managers/Chairs and other College Contacts:

•

Review the completed form, as submitted by the person involved in the incident.

•

For Critical Injuries, immediately report injury to Security Control Centre at 4400 so EHS Services can

ensure external reporting occurs

•

For Student incidents: If the student is on placement, attach a signed copy of the “Work/Education

Placement Agreement”

•

Complete Sections H and I

•

Attach any additional information relevant to this incident (witness statements, MSDS info sheets, etc)

•

For guidance on completing incident investigations go to

https://portal.myfanshawe.ca/campuslife/healthsafety/Pages/CHSMS.aspx

Instructions for Printing:

For Further Information, contact:

With the document open on your screen:

•

Environment, Health and Safety Services

Select the printer icon.

•

Room C2006

Select the Advanced button, bottom left

1001 Fanshawe College Blvd, P.O. Box 7005

corner.

•

London, ON

N5Y 5R6

Select Print as Image. Click OK.

E-mail: incident@fanshawec.ca

•

Click Print.

Owner: EHSS

Approved by: Manager, EHSS

Effective Date: Mar 2009

Version Date: May 2013

The controlled version of this document can be found on MyFanshawe. Any changes to this document or its defined processes must be approved by its owner. Hard

copies of this document are not controlled. To ensure you are always using the most current version, print this document directly from MyFanshawe as needed.

Incident Investigation Report - Fanshawe College

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