Incident Report Form - Cooper Custom Homes

This form must be completed by senior management and/or a supervisor whenever an incident occurs. An investigation of the occurrence must then be completed. A copy of the completed investigation report must also be forwarded to the OHS Committee/WHS Designate/WHS Representative.

Incident Category (Check all that apply)

Incident Specifics

Location of Incident:

Supervisor:

Date of Incident:

Time of Incident am/pm:

Date Reported:

Time Reported: am/pm:

Reported to:

Weather at Time of Incident

Temperature:

Wind:

Precipitation

Additional Details:

Employee Information

Employee Name:

Age:

Sex:

SIN: For Workplace NL Reporting ONLY

Home Address:

Occupation:

Length of Employment:

Phone Number:

Incident Information

Description of Incident:

Nature of Incident:

Body Part(s) Affected:

Physician Name:

Hospital Name:

Physician/Hospital Address:

Employee Left Work:

Date:

Time:

# Days Off:

Equipment/Vehicle/Property Involved:

Description of Damage:

Witness

Occupation

Contact Info

Statement Attached

Witness

Occupation

Contact Info

Statement Attached

Witness

Occupation

Contact Info

Statement Attached

Witness

Occupation

Contact Info

Statement Attached

Witness

Occupation

Contact Info

Statement Attached

Remedial Measure Taken By Supervisor

REPORT FORM DEFINITIONS

No Injury (Near Miss): an undesired event that, under slightly different circumstances, could haveresulted in personal injury, property damage or loss. First Aid Injury: a minor injury requiring only first aid treatment. Medical Aid Injury: an injury requiring treatment by a health care professional. Lost Time Injury: a disabling injury where the injured person is unable to report for the next regularshift. Illness: unhealthy condition in mind or body. Property Damage: accidental loss to equipment, material, and/or the environment. Motor Vehicle Accident: incident that occurred while operating or as a passenger of a motor vehicle