Hastings And Prince Edward School Supervisor'S Accident/violent Incident Investigation Report

Download a blank fillable Hastings And Prince Edward School Supervisor'S Accident/violent Incident Investigation Report 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 Hastings And Prince Edward School Supervisor'S Accident/violent Incident Investigation Report 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

FORM 421-2
Adopted
June 10, 2010
Last Revised
November 2014
Review Date
November 2015
Annual Review
SUPERVISOR'S ACCIDENT/VIOLENT INCIDENT
INVESTIGATION REPORT
CHECK ONE:  ACCIDENT  VIOLENT INCIDENT
School or Location:
Date of Accident/
Time of Accident/
Violent Incident:
Violent Incident:
Exact Location:
Date Reported:
Time Reported:
Injured Persons Name:
Reported By:
Occupation:
If violent incident: Name of Person/Student
Grade:
Exceptionality:
involved:
Injury Classification:
 No Lost Time
 Lost Time
Specify date(s)/time: ____________________________
 No Health Care Required
 Health Care Required Specify date(s)/time: ____________________________
 No First Aid Required
 First Aid Administered by Board Personnel
Specify name/date(s)/time: ____________________________________
 Return to work date (if applicable):
Description: Provide details of what\how accident/violent incident happened including names of any witnesses.
 Yes
 No
A sketch\picture of accident/violent incident is attached:
Analysis:
What were the obvious\underlying causes? List the actions, inactions, circumstances or conditions
contributing to this accident/violent incident.
Preventative Action:
Measures taken by supervisor to prevent reoccurrence.
Was employee conduct a factor in this incident?
 Yes  No
(i.e. misrepresentation, wilful misconduct, performing unassigned work, etc.)
Date:
Signature of Supervisor:
INSTRUCTIONS:
SEND THE INVESTIGATION REPORT TO HUMAN RESOURCES SUPPORT SERVICES IMMEDIATELY
FOLLOWING THE ACCIDENT/VIOLENT INCIDENT (within 24 hours, if possible)
ATTENTION:
HEALTH AND SAFETY OFFICER , HUMAN RESOURCES FAX: 613-966-1397 OR
EMAIL:
hr.services@hpedsb.on.ca

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Supervisor's Accident/injury Investigation Report Template Supervisor's Accident/injury Investigation Report Template Business
Supervisor's Accident Investigation Report Form Supervisor's Accident Investigation Report Form Business
Supervisor's Accident Investigation Form Supervisor's Accident Investigation Form Business
Accident/incident Investigation Report Accident/incident Investigation Report Business
Incident Investigation Report - Fanshawe College Incident Investigation Report - Fanshawe College Business
Dot Supervisor's Incident Investigation Report Of Occupational Injury Dot Supervisor's Incident Investigation Report Of Occupational Injury Legal
Dom Supervisor's Incident Investigation Report Of Occupational Injury Dom Supervisor's Incident Investigation Report Of Occupational Injury Business
Spo Supervisor's Incident Investigation Report Of Occupational Injury Spo Supervisor's Incident Investigation Report Of Occupational Injury Business
Form 421-1-employee Accident/violent Incident Report Form Form 421-1-employee Accident/violent Incident Report Form Business
Injury And Incident Investigation Report Form Injury And Incident Investigation Report Form Business

Related Categories

Parent category: Business
Download
Go