Incident Report

1. Type of Incident:

Fatality Loss Time Injury

x Medical Treatment Case First Aid

Near Miss

Does this incident require immediate reporting to the Government of Alberta Workplace Health and
Safety?

Yes No

2. Basic Incident Information:

Date and Time of Incident:

Location of Incident:

3. Involved Worker Information:

Name:

Position/Title:

Nature of Injury:

4. Incident Description:

Pre-incident

5. Causes:
6. Corrective Actions:

7. Follow up:
8. Investigation Team:
Moodle Books. (2018). Occupational Health and Safety. Retrieved from
https://moodle.nait.ca/course/view.php?id=52945

Audio Clip. (2018). Occupational Health and Safety. Retrieved from

https://moodle.nait.ca/course/view.php?id=52945