A BC C om pa n y LT D 12 3 M a i n Ro a d A n y T o wn , B C VO N 1 NO

Incident Investigation Report

Incident Type: Near Miss Exposure Injury Violence First aid Medical Attention Time Loss

Property Damage

3rd Party involvement

Address and/or description of where Incident Occurred:

Date:

Time:

Date/Time of Incident Reported to Employer: Date: Time: To: Injured and/or involved Person(s) Last Name First Name Position:

Dept/Job Title
(Indicate company name if not DNV)

Length of experience with this employer

Length of experience at this job/task

1) 2) 3) Nature of Injury/Injuries 1) 2) Witnesses Last Name 1) 2) 3) Persons conducting investigation Name Signature

First Name

Address/Dept

Telephone

Employer/Worker

Date

Document: 10101010

Detailed Description of incident (Describe incident in more detail. What was happening before and
after incident occurred. Add additional page if needed.)

Statement of Causes / Factors Contributing to the Incident. (List any unsafe conditions, acts, or
procedures that in any manner contributed to the incident.)

Recommendations (Identify any immediate corrective actions that have been taken, and any additional recommended actions to follow that will prevent similar accidents.) Action by Recommended Corrective Action Action by Whom Date 1)

2)

3)

4)

Please file a copy of this in the FA record book and send a copy to HR Dept attention WSBC Claims Coordinator.
Refer to A Guide to Accident/Incident Investigations eDoc 1789182 for additional information.

Document: 1784930