EMPLOYEE INCIDENT REPORT Last Name __ First Name Date

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					                                                                  EMPLOYEE INCIDENT REPORT
Last Name                                                                                            Home Telephone No.      (__ __ __) __ __ __ - __ __ __ __
__________________________________________________________________________
                                                                                                     Work Telephone No.      (__ __ __) __ __ __ - __ __ __ __
First Name                                  Date of Birth (DD/MM/YY)
___________________________________________       ___/___/___                                        Employee No. _________________________

Address
_______________________________________________________ City/Town _________________________________ Province __________________ Postal Code __ __ __ __ __ __
Gender (check) ‘ MALE ‘ FEMALE                                                                       Check       ‘ Full-time      ‘ Casual              Was the employee on the job when the injury
Department ______________________________________________________________                                        ‘ Part-time      ‘ Student             occurred? (Check)
Occupation at time of injury _________________________________________________                       Years of Experience ________                                   ‘ YES      ‘ NO
Date of Incident (DD/MM/YY)                       Date Reported (DD/MM/YY)                           To whom was the incident reported? _____________________________________
__ __/__ __/__ __                                 __ __/__ __/__ __                                  If a report is delayed, please explain why.
                                                                                                     ___________________________________________________________________________
Time of Day ____________ AM/PM                    Time Reported ____________ AM/PM                   ___________________________________________________________________________
State exactly the sequence of events leading up to the incident. Include an explanation of what      Location of incident                               Identify the sizes, weights & types of
the employee was doing.                                                                              ____________________________________               equipment involved
                                                                                                                                                        ____________________________________
__________________________________________________________________________                           What happened to cause the injury?                 ____________________________________
                                                                                                     What was the root cause?                           ____________________________________
__________________________________________________________________________                           ____________________________________
                                                                                                                                                        Type of incident (check one - definitions on
__________________________________________________________________________                           ____________________________________               reverse)
                                                                                                                                                        1 ‘ Struck by or contacted by
__________________________________________________________________________                           ____________________________________               2 ‘ Struck against/contact with
                                                                                                                                                        3 ‘ Caught in, on or between
__________________________________________________________________________                           ____________________________________               4 ‘ Fall/Slip
                                                                                                                                                        5 ‘ Overexertion
__________________________________________________________________________                           ____________________________________               6 ‘ Exposure
                                                                                                                                                        7 ‘ Repetitive action
                                                                                                     ____________________________________               8 ‘ Other
Names and addresses of witnesses or persons having knowledge of the incident.
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
Check all conditions that contribute to              6 ‘ Unsafe posture                                 12 ‘ Inadequate illumination                        18 ‘ Other - please explain
the incident                                         7 ‘ Working on moving or dangerous                 13 ‘ Fire, explosion, atmospheric                        _______________________
                                                         equipment                                           hazard                                              _______________________
1‘    Operating without authority                    8 ‘ Distracting, teasing, wilful                   14 ‘ Hazardous personal attire                           _______________________
2‘    Failure to secure or warn                          misconduct                                     15 ‘ unsafe design or arrangement
3‘    Working at unsafe speed                        9 ‘ Failure to use personal protective             16 ‘ Hazardous method or procedure                  19 ‘ Repetitive action
4‘    Unsafe equipment                                   equipment                                      17 ‘ Outside hazardous condition                    20 ‘ Sharps - related
5‘    Unsafe loading, placing, mixing               10 ‘ Wheeled equipment operation                                                                        21 ‘ Excessive load handling
      combing etc                                   11 ‘ Not guarded or improperly guarded
Direct causes (check one - see reverse)       1 ‘ Physical/Environmental         2 ‘ Personal          Basic causes (check one - see reverse)        1 ‘ Job factors       2 ‘ Personal factors
Action(s) taken                                                                       CORRECTED              PLANNED            Date (dd/mm/yy)             Examples of actions
                                                                                       (check box)           (check box)
                                                                                                                                                        1   Reinstruction of persons involved
1 _____________________________________________________________                             ‘                    ‘              ____/____/____          2   Reassignment of person
                                                                                                                                                        3   Order job safety analysis done
2 _____________________________________________________________                             ‘                    ‘              ____/____/____          4   Improved personal protective
                                                                                                                                                            equipment
3 _____________________________________________________________                             ‘                    ‘              ____/____/____        5     Action to improve inspection
                                                                                                                                                      6     Equipment repair or replacement
4 _____________________________________________________________                             ‘                    ‘              ____/____/____        7     Correction of congested area
                                                                                                                                                      8     Installation of guard or safety device
5 _____________________________________________________________                             ‘                    ‘              ____/____/____        9     Actions to improve design/procedure
                                                                                                                                                     10     Check with manufacturer
6 _____________________________________________________________                             ‘                    ‘              ____/____/____       11     Inform all department supervision
                                                                                                                                                     12     Discipline of persons involved
7 _____________________________________________________________                             ‘                    ‘              ____/____/____       13     Other:
                                                                                                                                                            _________________________________
Describe injury, part of body involved and specify left or right side.
__________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________
No injury (check one)                         Injury - No WSIB Claim (check one)                       WSIB Claim Treatment Memorandum (check one)
1 ‘ Hazardous Situation                       1 ‘ First Aid                                            1 ‘ Health care (medical aid)
2 ‘ Work refusal                              2 ‘ No aid                                               2 ‘ Lost time
3 ‘ Work stoppage
4 ‘ Property damage
Did employee seek medical attention? (Check one)               1 ‘ No 2 ‘ Yes                        Did employee visit family physician? (Check one)                1 ‘ No       2 ‘ Yes
Did employee visit health service? (Check one)                 1 ‘ No 2 ‘ Yes
Did employee visit emergency? (Check one)                      1 ‘ No 2 ‘ Yes                             if Yes, Family Physician Name _____________________________________________
     if Yes, ER Physician Name ________________________________________________
                           Tel. No. (__ __ __) __ __ __ - __ __ __ __                                                              Tel. No. (__ __ __) __ __ __ - __ __ __ __
Will the employee undertake                       Has the employee had a similar disability?         Check attachments to this report.
 (check one)                                      (Check one)                                        1 ‘ Statements
1 ‘ Regular duties                                1 ‘ Yes                                            2 ‘ Photographs
2 ‘ Modified duties                               2 ‘ No                                             3 ‘ Treatment memo
3 ‘ Remain off work                               3 ‘ Unknown                                        4 ‘ Other - specify: ___________________________________________________________


__________________________________            ____________                                             _____________________________            ___________________
EMPLOYEE SIGNATURE                            Date                                                     MANAGER SIGNATURE                        Date
                                EMPLOYEE INCIDENT REPORT

TYPES OF INCIDENTS - DEFINITIONS

1. Struck By or Contact By                          4   Fall/Slip
   An incident in which a person has been               Art incident can be subdivided into two
   struck abruptly or forcefully by some object         categories - a foot-level fall or a fall-below.
   in motion (e.g., box falls off shelf, employee       A foot-level fall occurs when a person slips,
   jabs needle into finger, person pushing cart         trips or falls on the same level on which
   runs into someone) or a person is contacted          he/she was standing or walking (e.g., a
   non-forcefully by some substance or agent            person slips on foreign matter on a floor).
   in motion which has an injury-upon-contact           Slips and trips should also be recorded
   characteristic (such as being splashed by hot        under this category. A fall-below occurs
   or corrosive solutions).                             when a person falls to below the level on
                                                        which he/she was standing or walking (e.g.,
2   Struck Against/Contact With                         a person falls from a ladder).
    An incident in which a person strikes
    abruptly or forcefully some stationary object   5   Overexertion
    in his/her surroundings (e.g., nurse strikes        An incident is one in which a person puts
    his/her leg against the crank of a bed) or          excessive strain on some part of his/her
    comes into contact non-forcefully with some         body (e.g., an employee strains his/her back
    stationary substance or agent which has an          or some other part of the body).
    injury-upon-contact characteristic (such as
    electrical shock).                              6   Exposure
                                                        An incident in which the employee is
3   Caught In, On or Between                            exposed to harmful conditions (e.g., toxic
    An incident in which a person is:                   gases, fumes or vapours; toxic airborn
    a) trapped in some type of enclosure or a           particles; extremes of heat or cold; oxygen
        part of a person’s body is caught in            deficient atmospheres; radioactive
        some type of opening (e.g., a person is         radiation., intense light brightnesses).
        caught in an elevator or locked into a
        refrigerated room).                         7   Repetitive Action
    b) caught on some protruding object (e.g.,          An incident that develops over a period of
        a person's clothing gets hooked onto a          time due to the repetitive nature of the task
        handle or a person catches his/her hand         beig carried out (e.g., pipetting,
        on a sharp edge).                               keyboarding).
    c) pinched, crushed or otherwise caught
        between either a moving object and a
        stationary object or between two or
        more moving objectives (e.g., a person
        jams his/her fingers between a wheeled
        cart and doorway).


DIRECT CAUSES - DEFINITIONS                         BASIC CAUSES - DEFINITIONS

Physical/Environmental                              Job Factors
Contributing conditions such as                     work procedures, purchasing, design, training,
machinery/equipment, housekeeping, physical         engineering controls, etc.
agents, personal protective equipment,
temperature (heat/cold), etc.                       Personal Factors
                                                    Physical restrictions, lack of training,
Personal                                            motivation, inadequate capability, etc.
Contributing actions such as unauthorized
equipment use, improper body motion, working
at unsafe speeds.