Incident Investigation Report - Fanshawe College Page 2
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3INCIDENT INVESTIGATION REPORT
Environment, Health and Safety Services – Room C2006
1001 Fanshawe College Blvd, P.O. Box 7005
RESET FORM
London, Ontario N5Y 5R6
Incident@fanshawec.ca
Employee
Student
Contractor
Visitor
Person involved:
Sections to complete:
A, B, C, F, G, I
A, B, D, F, G, I
A, B, E, F, G, I
A, B, E, F, G, I
Manager/Chair: Ensure all sections are completed, including H and I.
A. INCIDENT CLASSIFICATION
)
First Aid (immediate, on-site care
Near Miss/Hazardous Situation (no injury/potential for injury)
e.g. ice pack, bandage
Medical Aid (examination by health care provider)
Recurrence of previous injury
Provide claim no., if possible:
Lost Time (treatment, and absent from work)
B. PERSONAL INFORMATION OF PERSON INVOLVED
Male
Female
Full Name ________________________________________________________________
S.I.N.: _____________________________________
Date of Birth (dd/Mmm/yy)_________________________________
Address ________________________________________________
Telephone: (
) _______________________
City _____________________________
Province _________________
Postal Code _____________________________
C. EMPLOYEES TO COMPLETE THIS SECTION
Employee Number _________________ Name of Manager/Chair ________________________ Department __________________
Job Title _________________________ Length of Time in Position __________________
Hire Date (dd/Mmm/yy) ________
Union Member 109 110 NA
Shift Worker Yes No
If yes, indicate shift ____________________________
Normal work days and hours ___________________________________________________________________________________
D. STUDENTS TO COMPLETE THIS SECTION
Student Number ______________________ Campus Location ______________________________________________________
Program Name ____________________________________ Program Co-ordinator ______________________________________
Yes No
Was the incident program-related?
Did the incident occur on placement? Yes No
Yes No
If yes, is this a paid placement?
If yes, name of placement employer ______________________________________Telephone: (
)________________________
E. CONTRACTORS and VISITORS TO COMPLETE THIS SECTION
Contractor
College Contact ________________________________________________________________________________
Company Name and Address _____________________________________________________________________
Visitor
Reason for being at the College:
F. INCIDENT INFORMATION
Date of Incident (dd/Mmm/yy) ______________________________________ Time ___________________________a.m./p.m.
Date Reported (dd/Mmm/yy) _______________________________________ Time ___________________________a.m./p.m.
Reported to ______________________________________
Position ____________________ Telephone (
)______________
Individual(s) witnessing or having knowledge of the incident __________________________________________________________
___________________________________________________________________________________________________________
Location (campus/building/room/other) ___________________________________________________________________________
Describe the Incident (what you were doing and what happened), and any Injuries you Received
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.
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