If Other explain:
Was the Modified Work Program Implemented?
 Press play to hear tips on using this form. Modified work is a program for the placement of employees who are temporarily unable to perform the full range of their regular job duties, but who have been released by their physicians to return to work in a limited capacity. Modified work is a gradual re-employment plan for injured workers. Medically able to return to work, the injured worker can only work in a limited capacity, unable to do the full range of regular job duties. WCB has an example Modified Work form
Yes No
If a serious or fatal incident occurs, consider contacting a Legal Expert who has experience in this field.
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Provide a brief statement about the incident.
 Press play to hear tips on using this form. When writing your incident summary remember to include a description of the injuries sustained by the worker. Example: While using an angle grinder to smooth a welding bead, a piece of the disk flew off and hit a nearby worker in the back of his neck, resulting in a deep laceration and bleeding that required treatment at a hospital. NOTE: Be sure to include information on all previously checked incident categories.
Incident Sketch Form
 Press play to hear tips on using this form. The incident sketch is a very important process. It provides the location where an incident has occurred on a project. If you require an incident sketch, use this form and attach it to your final report.
(Also consider attaching all photos of the incident and location)
Was a Field Level Hazard Assessment (or equivalent) completed prior to the commencement of job related activities?
 Press play to hear tips on using this form. Field Level Hazard Assessment (FLHA) is a method that individuals and crews use to eliminate or minimize potential losses (to people, property, materials or environment) during the course of doing work. Field Level Hazard Assessment is a way for workers and crews to: - Identify hazards associated with work tasks and assess their risks on the day of the job
- Put controls in place so that risks are kept to an acceptable level
Field Level Hazard Assessment is a way for companies to: - Decrease risk and increase the reliability of work
- Reduce the number and associated costs of incidents
The process of Field Level Hazard Assessment includes: - Tools that help workers stop, think and put controls in place
- Training for supervisors and workers
- Sample forms that can be used to document field level hazard assessments and make improvements
- A manager's, supervisor's, and worker's handbook
(Downloadable at Construction Owners Association of Alberta (COAA) website))
* Additional resources available at the ACSA include: FLHA Pre-Task Checklist Forms( Page 1, Page 2) and DVD/VHS Training Videos.
Yes No
Comments:
The following three pages contain selection tables for identifying contributing circumstances. There are separate tables for Job Factors, Management Factors and Personal/Natural Factors. Check all that apply through both direct and indirect causes.
(Include Direct and Indirect Causes)  Press play to hear tips on using this form. Direct Causes Immediate direct causes of incidents may be attributed to substandard practices or substandard conditions. These are the hazards that exist immediately prior to the incident. Immediate direct causes are the symptoms of deeper problems. Indirect Causes The underlying causes of an incident are "any job/management/personal factors that contributed to the immediate direct causes." These are the real causes behind the symptoms. They are not as apparent as the immediate direct causes.
Please select all that apply (must select at least one):
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If none of the above sections are appropriate, please describe the job factors here.
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Check all that apply. When selecting "Other", please provide a suitable explanation.
Please select all that apply (must select at least one):
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Check all that apply. When selecting "Other", please provide a suitable explanation.
Please select all that apply (must select at least one):
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Check all that apply. When selecting "Other", please provide a suitable explanation.
Was there any reasonable cause testing as a result of the incident?
 Press play to hear tips on using this form. Reasonable cause testing is explained in the "Alcohol and Drug Guideline - A Canadian Model" available on the COAA website. Following the COAA "Canadian Model" will assist your company in meeting the legal obligations associated with reasonable cause testing
Yes No
Explain:
What immediate action(s) was/were taken?
 The Help Topic could not be located.
Person(s) who implemented immediate action(s).
Have corrective actions been taken?
Yes No
Comments:
Person(s) responsible for implementing corrective actions.
Scheduled time frame for completion:
Actual date or dates of Completion:
Have witness statements been taken? Yes No
Have these statements been properly signed by the witness? Yes No
Has an Incident Sketch  Press play to hear tips on using this form. The incident sketch is a very important process. It provides the location where an incident has occurred on a project. If you require an incident sketch, use this form and attach it to your final report. been completed by the witness(es)? Yes No
Are the original witness statements  Press play to hear tips on using this form. It is important that the original witness statement forms be attached to the master investigation file. attached to this report? Yes No
If witness statements have been completed but are not attached, identify where they can be obtained. Explain.
Was there a regulatory requirement to report this incident?
 Press play to hear tips on using this form. OCCUPATIONAL HEALTH AND SAFETY ACT 18(1) If an injury or accident described in subsection (2) occurs at a work site, the prime contractor or, if there is no prime contractor, the contractor or employer responsible for that work site shall notify a Director of Inspection of the time, place and nature of the injury or accident as soon as possible. (2) The injuries and accidents to be reported under subsection (1) are (a) an injury or accident that results in death, (b) an injury or accident that results in a worker's being admitted to a hospital for more than 2 days, (c) an unplanned or uncontrolled explosion, fire or flood that causes a serious injury or that has the potential of causing a serious injury, (d) the collapse or upset of a crane, derrick or hoist, or (e) the collapse or failure of any component of a building or structure necessary for the structural integrity of the building or structure.
Yes No
Which regulatory authority  was contacted?
Provide name of person who contacted the authority, job title and company name
Provide date and time of contact. Date:  Time:
(24 hour clock)
Provide the regulatory contact name(s), job title(s) and phone number(s).
Did the regulatory authority conduct an investigation? Yes No
Were there any third party investigators (other than regulatory) involved with this incident?
 Press play to hear tips on using this form. Third party investigators could include forensic experts, environmental consultants, insurance investigators, legal advisors, investigation experts and health experts. REMEMBER: If a serious or fatal incident occurs, consider contacting a legal expert who has experience in this field.
Yes No
Was it necessary to contact our insurance carrier (other than WCB)?
Yes No
 Press play to hear tips on using this form. Remember most insurance carriers have reporting time limits, which must be adhered to. In some circumstances Insurance carriers require immediate notification to allow their independent inspectors access to the incident scene prior to evidence being disturbed.
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