Incident Investigation Report

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Type Of Incident
Close Call (No-Loss Incident) First Aid Medical Aid
Lost Time Environment Fatality
Other  
If Other explain:


Was the Modified Work Program Implemented?
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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.
Company / Project / Worker Information
Name of Company / Companies:
Date of Incident: Click Here to Pick up the date
Time of Incident (24 hour clock):

Do you have a WCB Account Number? Yes No
WCB Account #:

Do you have a Reference File Number? Yes No
Reference File # or Name:

 
Name of Project:
Project Location:
Incident Location:
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In this area be specific to the location - i.e. boiler room of fabrication shop, SE road entrance to project etc.

Name of Supervisor:

Workers Involved: (Use Add or Subtract button to create or remove lines)
Worker(s) Name Gender Occupation Employee #
Select Incident Category(ies)

Hazardous Condition Injury Illness Vehicle Incident
Property Damage Equipment Damage Fire / Explosion Equipment Failure
Regulatory Order Occupational Exposure (Disease) Other(s) - Please Specify  

Community Complaint Hazardous Condition Spill Release
Noise Regulatory Order Other(s) - Please Specify  

Theft / Robbery Threat Violence Security Breach
Vandalism Fraud Bomb Threat Labour Disruption
Other(s) - Please Specify  
Incident Summary
Provide a brief statement about the incident.
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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
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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)

Hazard Assessment
Was a Field Level Hazard Assessment (or equivalent) completed prior to the commencement of job related activities?
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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:
 
If answered Yes, specify the date, location, time and by whom.
 
Date: Click Here to Pick up the date Time: (24 Hour Clock)
 
Location:
 
Name of the person who did the assessment, include the job title and name the employer.
Name(s):
Job Title(s):
Name of Employeer:
Duties and Responsibilities
At the time of the incident, was/were the worker(s) performing work activities which are/were part of their regular duties and responsibilities? Yes No
 
If answered NO, explain.
Contributing Circumstances
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)
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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.

Job Factors
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Job Factors
These are the work environment factors such as inadequate tools, equipment, or materials.

Substandard Conditions
A substandard condition is "any hazardous arrangement which, if left uncorrected, may lead to an incident."

NOTE: Check all that apply. When selecting "Other", please provide a suitable explanation.
Please select all that apply (must select at least one):

Not developed Inadequate procedure or practice Procedure or practice not followed Inadequate communication of procedure
Inadequate assessment of risk Not implemented Other(s) - Please Specify  

Availability Defective Inadequate maintenance No inspection
Tool used incorrectly Inadequate assessment of tools for the task Other(s) - Please Specify  

Inadequate hazard assessment Design process not followed Inadequate assessment of ergonomic factors Inadequate assessment of operational capabilities
Inadequate programming Other(s) - Please Specify  

If none of the above sections are appropriate, please describe the job factors here.


Check all that apply. When selecting "Other", please provide a suitable explanation.
Management Factors
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Management Factors
These are factors attributed to the management process regarding planning, communication, knowledge and skill requirements including education and training.

Substandard Practices
A substandard practice of any individual is "any departure from an accepted, normal, or correct procedure or practice that permits the occurrence of an incident."

Substandard Conditions
A substandard condition is "any hazardous arrangement which, if left uncorrected, may lead to an incident."

NOTE: Check all that apply. When selecting "Other", please provide a suitable explanation.
Please select all that apply (must select at least one):

Inadequate work planning Inadequate management of change Conflicting work plans Inadequate assessment of needs and risks
Inadequate documentation Other(s) - Please Specify  

Unclear responsibilities and accountabilities Lack of communications Inadequate direction or information Misunderstood communications
Other(s) - Please Specify  

Inadequate training/ orientation Training needs not identified Lack of coaching Inadequate assessment of needs and risks
Other(s) - Please Specify  


Check all that apply. When selecting "Other", please provide a suitable explanation.
PERSONAL FACTORS / NATURAL FACTORS
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Personal Factors
These include factors such as lack of knowledge or skill, stress, improper motivation, inadequate capability, or impairment.

NOTE: Check all that apply. When selecting "Other", please provide a suitable explanation.
Please select all that apply (must select at least one):

Physical capabilities (height, strength, weight, etc.) Sensory deficiencies (sight, sound, sense of smell, balance, etc.) Substance sensitivities /allergies Language barrier
Other(s) - Please Specify  

Failure to address hazard Conflicting demands / priorities Emotional stress Fatigue
Extreme judgment demands Substance abuse Failure to recognize hazard Other(s) - Please Specify

Fire Flood Extreme weather (cold, heat, wind) Tornado
Earthquake Other(s) - Please Specify  


Check all that apply. When selecting "Other", please provide a suitable explanation.
Drug and Alcohol Testing
Was there any reasonable cause testing as a result of the incident?
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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:

Immediate Action
What immediate action(s) was/were taken?
The Help Topic could not be located.


 
Person(s) who implemented immediate action(s).
Name Position / Title Company Action Taken

Corrective Action
Have corrective actions been taken?
Yes No
Comments:

 


 
Person(s) responsible for implementing corrective actions.
Name Position / Title Company Action Taken

 
Scheduled time frame for completion:

 
Actual date or dates of Completion:

Assistance Rendered
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First aid - First aid is limited to a one-time treatment, with follow-up visit if needed, for observation purposes only, of injuries such as minor cuts, scrapes, scratches, treatment of minor burns, removing splinters etc. or other minor injuries which do not require medical treatment beyond the date of accident.
First aid is the type of treatment performed regardless of who performs the treatment. In most cases, first aid treatment is provided by a first aid practitioner. However, there may be situations when the first aid treatment is provided by a physician or at a medical facility. These possibilities are more likely when:
  • the hospital or health facility is the workplace
  • the employer has on-site health care practitioners and health facilities
  • the employer has specific contracts with health care facilities to provide first aid and health care to their workers

If the professional skills of a health care professional are required, and a first aid practitioner could not have provided the care and evaluation, the treatment is not first aid and should be reported to WCB

Medical aid - Section 1(1)(p) states that medical aid includes medical and other services provided by a person licensed to practice the healing arts in Alberta, and nursing, hospitalization, drugs, dressing, x-ray treatment, special treatment, appliances, apparatuses, transportation and any other matters and things that the Board authorizes or provides.
Coverage is also extended when an accident results in the loss, damage or breakage of an artificial limb, eyeglasses, dentures etc.
Medical aid that is considered first aid does not need to be reported to WCB.
Was medical assistance administered on-site? Yes No N/A
 
By whom?
Name Company Worked For Position / Title

 
What type of on-site medical assistance was administered? (Specify)

 
Was worker sent to an off-site medical facility? Yes No N/A
 
Provide name, type of facility and address of facility.
Name Type of Facility Address of Facility

Was stress management provided? Yes No N/A
Explain:

 
Modified Work
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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
Was the modified work form submitted to the attending doctor? Yes No
 
How did the injured worker get to the medical facility (specify i.e., ambulance, company vehicle, etc).

 
Did someone from the work-site accompany the injured worker? Yes No
 
Fill in the name, job title and company they worked for.
Name Job Title Company
WCB Information
Was the WCB Employer Report completed and sent in to WCB within the legislated time limit (72 hours in Alberta)? Yes No Not Applicable
 
Identify company, person and job title (who submitted).
Company Person Job Position

WCB Worker Report Forms
WCB Employer Report Forms
Witness Statements
Have witness statements been taken? Yes No
 
Have these statements been properly signed by the witness? Yes No
 
Has an Incident Sketch
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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
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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.

Witness Statement Form
Incident Sketch Form
Site Evacuation
Was there a site evacuation? Yes No N/A
Comment/Explain:

 
Is the Site Evacuation Report attached to this report? Yes No
 
If a Site Evacuation Report has been completed but is not attached, identify where the report can be obtained. Explain.

 
Site Evacuation Report form
Regulatory Reporting
Was there a regulatory requirement to report this incident?
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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?
Environmental OHS Health
Police Other(s) - Please Specify  

 
Provide name of person who contacted the authority, job title and company name
Name Job Title Company

 
Provide date and time of contact. Date:Click Here to Pick up the date Time: (24 hour clock)
 
Provide the regulatory contact name(s), job title(s) and phone number(s).
Agency Name Job Title Phone Number