Incident Investigation Report - Fanshawe College Page 3
Download a blank fillable Incident Investigation Report - Fanshawe College in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Incident Investigation Report - Fanshawe College with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3F. INCIDENT INFORMATION
Name: _________________________________________
continued
Sudden Specific
Gradually Occurring Over Time
Was the Incident/Illness:
Type of Incident:
Cut/Scrape
Overexertion
Needlestick/Puncture
Burn
Slip/Trip
Repetitive
Assault
Fire/Explosion
Fall
Struck/Caught
Harmful Substances/Environmental
Motor Vehicle
Other (please specify) ______________________________________________________________________________________
Area Affected (Body Part) – Please check all that apply
Left Right
Left Right
Left Right
Left Right
Upper Back
Ankle
Head
Teeth
Shoulder
Wrist
Hip
Lower Back
Upper Arm
Face
Neck
Hand
Thigh
Foot
Eye(s)
Fingers
Toe(s)
Chest
Abdomen
Elbow
Knee
Lower Leg
Ear(s)
Pelvis
Forearm
Other – please clarify.
Have you had a prior, similar problem? Please clarify.
G. FIRST AID, MEDICAL AID and LOST TIME / NO LOST TIME
Describe First Aid treatment, if applicable:
For Medical Aid and Lost Time, provide the following:
Name of attending doctor/facility _______________________________________________________________________________
Address ___________________________________________________________________________________________________
Telephone (include area code) (
) _____________________Date seen (dd/Mmm/yy) ______________________________
Date when the College learned of visit to doctor or other health care provider (dd/Mmm/yy)______________________________
Yes
No
After the date of incident, have you lost any time or earnings from your job/placement/classes?
Start date of lost time (dd/Mmm/yy)___________Date of return (dd/Mmm/yy) ___________ Returned to Regular
Modified
Yes
No
Has an Absence Report been forwarded to HR identifying WSIB Lost Time?
H. MANAGER’S/CHAIR’S INCIDENT FOLLOW-UP and ACTION PLAN
What were the causes of this incident? (Consider contributing factors, conditions, unsafe acts, personal/job factors.)
Was personal protective equipment used at the time? Please clarify. _____________________________________________________
____________________________________________________________________________________________________________
Was property damaged (vehicle/equipment/materials)? Please clarify. ___________________________________________________
____________________________________________________________________________________________________________
Manager/Chair Action Plan (Describe action to be taken and any recommendations.)
1. __________________________________________________________________________________________________________
2. __________________________________________________________________________________________________________
3. __________________________________________________________________________________________________________
Manager/Chair Responsible _______________________________________________ Date (dd/Mmm/yy) ___________________
I. SIGNATURES –
E-mail completed document, within 24 hours of the incident, to:
Involved
1) Environment, Health & Safety Serv. (Incident@fanshawec.ca) 2) Manager/Chair and/or Designate 3) Person
(Note: signature is NOT required if form is completed electronically, and a copy is e-mailed to person involved and his/her manager)
Person Involved (print clearly) ___________________________________________
Dept. Code (3-char.) ________________
Signature ____________________________________________________________
Date (dd/Mmm/yy) ________________
Manager/Chair or College Contact (print clearly) _____________________________
Dept. Code (3-char.) ________________
Signature ____________________________________________________________
Date (dd/Mmm/yy) ________________
FOR OFFICE USE ONLY:
Reviewed by EHSS (print clearly) ________________________________________
Date (dd/Mmm/yy) ___________________
Signature ____________________________________________________________
PRINT
SUBMIT
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.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business