EHS-002

Health & Safety Solutions

ADVERSE EVENT /ACCIDENT INVESTIGATION FORM

DATE OF ADVERSE EVENT TIME OF ADVERSE EVENT

EMPLOYEE/S INVOLVED IN ADVERSE EVENT / CLOCK NO/’S AGE/S

WRITE PRIVATE WHEN CONFIDENTIALITY IS REQUIRED:

DAY OF THE WEEK MON TUE WED THU FRI SAT SUN

DEPARTMENT/S REGULAR OCCUPATION/S

YEARS OF COMPANY SERVICE PERIOD IN PRESENT JOB/S

NAME OF SUPERVISOR/S NAME OF DEPARTMENT HEAD/S

ACCIDENT INVESTIGATOR/S DATE OF INVESTIGATION:

ADVERSE EVENT CLASSIFICATION Disabling Injury Chronic Illness Minor Injury Damage

GENERAL AGENCIES OCCUPATIONAL HYGIENE AGENCIES

STRUCK BY FALL HANDLING TRANSPORT CHEMICAL FUMES FIRE GAS

STRUCK AGAINST FALLING OBJECT MACHINE ELECTRICITY DUST NOISE VAPOUR TEMPERATURE

PART OF BODY AFFECTED HEAD NECK EYE TRUNK FINGER HAND

ARM TOE FOOT LEG INTERNAL MULTIPLE

EFFECT ON PERSON SPRAINS STRAINS CONTUSION WOUNDS FRACTURES BURNS

AMPUTATION ELEC. SHOCK ASPHYXIATION UNCONSCIOUS POISONING MULTIPLE

NATURE OF INJURY (Describe the injury

eg laceration left hand index finger) or
ILLNESS DIAGNOSIS

CAUSAL AGENT

EVENT
1. Where did the adverse event occur?
2. What was the location?
3. What activity was the employee/s engaged in?
4. What equipment was involved?
5. Describe the adverse event as seen by the investigating team:

OUTCOME
1. Provide details of degree of treatment provided?

2. How many Days Lost?

3. Provide details of Work Restrictions?

4. Provide details of Work Transfer?

5. Provide details of Death?

6. Provide details of Property Damage?

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7. Provide details of Environmental Damage?
8. Provide details of Community or Company Impact?

CAUSUAL ANALYSIS

AT-RISK BEHAVIOUR UNSAFE CONDITION ROOT CAUSE EHS MANAGEMENT SYSTEM

FAILURE

IMMEDIATE ACTION PLAN Indicate: ACCOUNTABLE ACCOUNTABLE TARGET DATE

Low; PERSON NAME PERSON COMPLETION COMPLETE
Medium or SIGNATURE DATE
High-Priority

1.

2.

3.

4.

REMEDIAL ACTION PLAN

5.

6.

7.

8.

PREVENTIVE ACTION PLAN

9.

10.

11.

12.

REPORTING REQUIREMENTS:

Report to Department of Labour Report/s required: Accountable for completing report/s: Deadline for Date report
submission: sent:

Report to Other/ Specific Illness Report/s required: Accountable for completing report/s: Deadline for Date report
Reports submission: sent:

SIGNATURE OF INJURED SIGNATURE OF SIGNATURE OF HEAD OF SIGNATURE OF EHS SIGNATURE OF

PARTY / EMPLOYEE DEPARTMENT MANAGER DEPARTMENT INDUSTRIAL HYGIENIST
INVOLVED REPRESENTATIVE

Name of Health and Safety Rep. of area / section where the accident has occurred: Signature:

ATTACH A PHOTO OF THE ADVERSE EVENT WHEN REQUIRED

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