CONTRACTOR MONTHLY SAFETY REPORT

Company Name: Click here to enter text.

Project Name/Location: Click here to enter text.

Project Start Date: Click to choose date. Finish Click here to choose a date.

Incidents This Month Total Cause of Injuries This Month Total

Near Miss (NM) Enter here. Enter here. Trips, Slips or Falls Enter here. Enter here.
First Aid (FA) Enter here. Enter here. Eye Injuries Enter here. Enter here.
Medical Aid (MA) Enter here. Enter here. Falling Objects Enter here. Enter here.
Property Damage (PD) Enter here. Enter here. Material Handling Enter here. Enter here.
Lost Time Incidents (LTI) Enter here. Enter here. Others:
Click here to enter text. Enter here. Enter here.
Click here to enter text. Enter here. Enter here.
TOTAL CASES Enter here. Enter here. TOTAL CASES Enter here. Enter here.

Total No. Safety No. Orientations

Enter Number Enter Number Enter Number
Employees: Meeting(s): this Month:
Have all employees on site attended a safety orientation? ☐ Yes ☐ No
If no explain: Click here to enter text.

Brief description of work performed: Click here to enter text.

Enter Name . choose date. enter name choose date.

Completed by Contractor Date Project Safety Coordinator Date

Enter Name choose date Enter Name choose date

Reviewed by Date U of A Project Manager Date

DEFINITIONS:
 Near Miss (NM): An undesired event which, under slightly different circumstances, could have resulted in personal harm, loss of
process, property and/or environmental damage.
 First Aid (FA): When immediate treatment is rendered by a qualified person and the worker immediately returns to work.
 Medical Aid (MA): An injury that requires treatment by a physician beyond simple first aid care but does not result in time lost from
work beyond the day of the injury.
 Property Damage (PD): Damage to or the destruction of public or private property, caused either by a person who is not its owner or
by natural phenomena.
 Lost Time Incidents (LTI): An accident where a physician directs the injured worker to remain away from work longer that the day of
the accident.

Note: All contractor information and forms can be found on the Contractor Safety Webpage
(www.facilities.ualberta.ca/Operations_Maintenance_FO/Health_and_Safety_Program/ContractorSafety.aspx)

SEND THE COMPLETED REPORT TO Facilities and Operations Safety Division

(Copy to the University of Alberta Project Manager) Fax (780) 492-9692 or e-mail fosafety@ualberta.ca

ContractorSafety/document1 Revised: March 2014