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ACCIDENT/INCIDENT INVESTIGATION PROCEDURE

SEPTEMBER 2001

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A CRITICAL INJURY MUST BE IMMEDIATELY REPORTED


Critical injuries consist of any injury which: places life in jeopardy; produces unconsciousness; results in substantial loss of blood; involves the fracture of a leg or an arm but not a finger or toe; involves the amputation of a leg, arm, hand or foot, but not a finger or a toe; consists of burns to a major portion of the body; or causes the loss of sight in an eye.

If any of these serious injuries occur:

1. 2. 3.

CALL FOR EMERGENCY SERVICES ADVISE YOUR SUPERVISOR CALL THE BOARD'S HEALTH AND SAFETY DEPARTMENT AT 905-890-0708.

An investigative team of Joint Health and Safety Committee Members will respond as soon as possible.

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EXECUTIVE SUMMARY ACCIDENT INVESTIGATION PROCEDURE An Accident/Incident is an unplanned, unwanted event which disrupts the orderly flow of activities and may or may not involve injury to people or damage to equipment and materials. An essential part of the Board's Health and Safety program is the investigation of all employee accidents/incidents in the workplace. Incident Investigation Reports record the required data and identify corrective measures, areas of concern and can be used to identify trends. The Incident Investigation Report also fulfils the Board's requirement under the Occupational Health and Safety Act to investigate all critical injuries and fatalities and to submit a written report to the Ministry of Labour. The attached sequencing chart details the procedure for reporting an accident/incident. The employee is responsible for notifying their Principal/Supervisor of an accident/incident. In the event of any injury, the employee is also required to contact the Benefits Department in compliance with the Workplace Safety and Insurance Act. The Principal/Supervisor or designate completes and signs an Incident Investigation Report as soon as practical after the accident/incident and makes recommendations for corrective actions (i.e. work orders). The report is distributed as noted and if necessary the Health and Safety Department will analysis and follow up with Principal/Supervisor and the Joint Health and Safety Committee. For further information on conducting investigations, the Principal/Supervisor or designate should refer to the detailed Accident/Incident Investigation Procedure in the Health and Safety Manual.

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ACCIDENT/INCIDENT REPORTING SEQUENCING CHART


Accident/Incident

Near Miss (No Injury, Lost Time, Medical Attention)

Injury (First Aid, Medical Attention, Lost Time)*

Report to Principal/Supervisor (Employee Responsibility)

Report to Principal/Supervisor (Employee Responsibility)

Report to Benefits Department by employee or if unable, then by Principal/Supervisor

Completion of Incident Investigation Report Form by Principal/Supervisor FAX WITHIN 24 HRS. TO BENEFITS DEPARTMENT @ 905-890-0421

Distribute all copies within 24 hrs.

Principal/Supervisor

Employee

Health & Safety Department (Recommendation)

Joint Health & Safety Committee (Study & Recommend)

If injury is critical (see pg. 9-2) as defined by the Occupational Health and Safety Act, Call Health and Safety IMMEDIATELY!

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Table of Contents
1.0 ROLE OF ACCIDENT/INCIDENT INVESTIGATION 1.1 1.2 1.3 Purpose of the Accident/Incident Investigation Benefits of Investigating the Accident/Incident Types of Accident Investigations 1.3.1 1.3.2 The Employer's Report of Accidental Injury or Industrial Disease (WSIB Form # 7) Critical Injury Report

2.0

PLANNING FOR ACCIDENT/INCIDENT INVESTIGATION 2.1 Aspects of the Investigation

3.0

CONDUCTING ACCIDENT/INCIDENT INVESTIGATION 3.1 3.2 Steps to Ensure Reporting of Accidents/Incidents Information Requirements 3.2.1 3.2.2 3.2.3 3.2.4 3.3 3.4 Floor Plan Equipment Inventory WHMIS Inventory Incident Investigation Report

Roles and Responsibilities Investigation Procedures 3.4.1 3.4.2 3.4.3 3.4.4 Physical Evidence Interviewing Accident/Incident Causation Analysis Recommendations

9-6 .0 ROLE OF ACCIDENT/INCIDENT INVESTIGATION Incident Investigation Reports are an essential part of the Board's health and safety program. Investigations of all employee accidents/incidents in the workplace along with recording of required data and appropriate corrective measures identify areas of concern. Analysis of all reports for trends assists in addressing these concerns to prevent future recurrences of accidents/incidents and injuries ultimately ensuring a healthy and safe environment for students, staff and the community. 1.1 Purpose of the Accident/Incident Investigation An accident is an unplanned, unwanted event which disrupts the orderly flow of activities and may or may not involve injury to people or damage to equipment and materials. An incident is an undesired event, which, under slightly different circumstances, could have resulted in harm to people, damage to property, or loss to process. The goal of accident/incident investigations can be summarized in one word PREVENTION. 1.2 Benefits of Investigating the Accident/Incident There are many benefits of a prompt and thorough accident/incident investigation. 1. 2. Prompt investigations demonstrate concern for the employee's wellbeing. Effective accident/incident investigations reduce lost time. This directly reduces direct and indirect cost, in both human suffering and financially. Accidents/incidents are not only time consuming, but expensive. Accident/incident investigationand the resulting prevention are tangible evidence of the ability and efficiency of the Board's health and safety programs. Increasingly, safety performance is coming under scrutiny by employees, government and the public.

3.

1.3

Types of Accident/Incident Investigations Other types of accident/incident investigations in the Board include: 1.3.1 The Employer's Report of Accidental Injury or Industrial Disease (WSIB Form # 7) The GAP Handbook Procedure # 310.00 requires any employee having a work-related accident or industrial disease to report this fact to the Benefits Department immediately. The Workplace Safety & Insurance Act requires completion of the WSIB Form # 7 reports for any work related accident or industrial disease where the injured employee requires medical attention. These reports are completed and submitted to the WSIB by the Benefits Department. 1.3.2 Critical Injury Report The Occupational Health and Safety Act and Industrial Establishment Regulations require investigation of critical injuries and fatalities with a written report, submitted to the Ministry of Labour within forty eight hours of the occurrence. This investigation and report is to be performed jointly by a management and worker member of the Joint Health and Safety Committee.

2.0

PLANNING FOR ACCIDENT/INCIDENT INVESTIGATION Preparing for accident/incident investigations is essential to ensure the reports are accurate and applicable. The Principal/Supervisor is responsible for the health and safety of their employees and investigation of the accident/incident. Completion of the Incident Investigation Report with appropriate follow-up assists in meeting this responsibility

97 . 2.1 Aspects of the Investigation An effective accident/incident investigation identifies the causes of the accident. Every investigation must examine who, what, where, when, and how. What is an Accident/Incident Investigation A complete accident/incident investigation includes the objective evaluation of all facts, opinions, statements, physical evidence and related information, as well as defined action steps to reduce the possibility of recurrence. When is an Accident/Incident Investigated The best time for an accident/incident investigation is as soon as possible. Facts and details of the accident are clearest and conditions of the accident/incident scene are nearest to those present at the time of the accident/incident. The investigation begins as soon as the needs of the injured employee(s) are addressed. Why is an Accident/Incident Investigated The purpose of an accident/incident investigation is to prevent a recurrence of the accident/incident by identifying the root cause(s). With PREVENTION in mind, the focus of the investigation will be simplified. 3.0 3.1 CONDUCTING ACCIDENT/INCIDENT INVESTIGATION Steps to Ensure Reporting of Accidents/Incidents An unreported accident/incident may not be investigated, nor its causes corrected. Ensure that all accidents/incidents are reported by: 1. Emphasizing the need to report all accidents including a near miss incident and property damage as deemed appropriate. Situations cannot be corrected unless they are reported, and an accident/incident could repeat itself with more serious results. Expressing appreciation when an accident/incident is reported. Reinforce dissatisfaction with late reporting. Acting on all reports immediately. Investigate the accident/incidentand take the required corrective measures.

2. 3. 3.2

Information Requirements The following information will assist in the accident/incident investigation. 3.2.1 Floor Plan Using current floor plans visualize the activities at the accident/incident scene and identify the location of equipment and materials that may have been involved.

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3.2.2

Equipment Inventory Know what condition and type of equipment and materials were involved in the accident/incident.

3.2.3

WHMIS Inventory If a chemical was involved in the accident/incident, find out whether actual and potential sources of chemical exposure were properly controlled. WHMIS inventories must be updated annually and current Material Safety Data Sheets must be available. Ensure that all employees have received training in handling chemicals. Check that chemicals were labelled with pertinent information, such as identification, handling, storage, and waste disposal, according to Workplace Hazardous Materials Information System (WHMIS) requirements.

3.2.4

Incident Investigation Report The Incident Investigation Report must be completed for employee accidents/incidents occurring at schools/administrative buildings.

3.3

Roles and Responsibilities Principal/Supervisor The Principal/Supervisor shall conduct an accident/incident investigation as soon as practical after the accident/incident has occurred. Where possible include the health and safety liaison or representative in the investigation. Acquire all information regarding the accident/incident including eyewitness accounts and obtain data from persons having knowledge of the situation. Where an accident involves a critical injury the Health and Safety Department must be notified immediately. In the case of a serious accident/incident the accident scene must remain undisturbed, except for emergency services. The Incident Investigation Report must be completed immediately upon completion of the investigation and distributed as noted within 24 hrs. Submit copies of work orders, letters, witness statements, and other supplementary information. When permanent correction cannot be made immediately, temporary measures, such as roping off the area, tagging out equipment or posting warning signs should be utilized. Superintendents Where health and safety issues cannot be resolved by the Principal/Supervisor, the Superintendent shall take appropriate action such as providing recommendations, allocating personnel and/or budgetary requirements and consult with Senior Administration. Health and Safety Department The Health and Safety Department shall analyze all Incident Investigation Reports, and where necessary, provide recommendations for corrective action and/or preventive measures on the Incident Investigation Report. Where recommendations are made, they will be communicated to the Principal/Supervisor.

9-9 Joint Health and Safety Committee The Joint Health and Safety Committee shall evaluate the Incident Investigation Report and provide recommendations for corrective action and/or preventative measures. Staff During the accident/incident investigation, staff will provide the Principal/Supervisor with information and assistance which may pertain to the accident/incident or circumstances leading to the accident/incident. 3.4 Investigation Procedures The steps in an accident/incident investigation are simple: gather information analyze draw conclusions make recommendations

The accident/incident investigation process will vary depending on the nature of the accident/incident. Keep an open mind to all possible causes, as preconceived notions may lead down the wrong path with significant factors left uncovered. Make notes of ideas as they occur but try to avoid drawing conclusions until all information is gathered. For any accident, the priority is medical treatment of the injured and prevention of further injuries. When these matters are under control, the Principal/Supervisor can begin the investigation. Before attempting to gather information, examine the site and identify all witnesses. 3.4.1 Physical Evidence Physical evidence may be subject to rapid change or obliteration. For this reason it must be recorded first. Check for the following items: - position of injured person - equipment used - material used - safety device used - position of the appropriate guards - position of the controls of the machinery - damage to equipment - housekeeping of area - weather conditions - lighting levels - noise levels A sketch or photograph can be taken of the accident/incident site for further analysis later. Broken equipment, debris and samples of materials involved may be removed for further analysis by appropriate experts.

9 - 10 3.4.2 Interviewing Interviewing the injured person and witnesses represents another source of information. This should be done as soon as practicable after the accident to ensure the information has not been influenced by others. Interview each person individually at the scene, where it is easiest to obtain a description of the events or in the peace and quiet of an office, where there will be fewer distractions. It is important to conduct the interview with the witnesses (injured person), in as calm an environment as possible. To assist in establishing a good rapport with the person being interviewed and whose own words you want for the description, here are some Dos and Don'ts: Do put the person, who may be upset, at ease emphasize the real reason for the investigation let the person talk confirm that the statement is correct make short notes only during the interview

Don't

- intimidate the person - interrupt - prompt - ask leading questions - show your emotions - make lengthy notes while the person is talking.

The actual questions you ask the person will vary with each accident/incident, but there are some general questions that should be asked: 1. 2. 3. 4. 5. 6. 7. Where were you at the time of the accident/incident? What were you doing at the time of the accident/incident? What did you see or hear? What were the environmental conditions (weather, light, noise etc.) at the time? What was the injured person doing at the time? In your opinion, what caused the accident/incident? How might similar accidents/incidents be prevented?

If you were not at the scene at the time, questions are the most straightforward approach to establish what happened. Care must be taken to assess the credibility of any statement made in the interviews. Answers to the first two suggested questions will give an indication of how well the witness was able to observe what happened. An additional technique sometimes used to determine the sequence of events is to replay them as they occurred. Obviously, great care must be taken so that further injury or damage is not incurred. A witness (usually the injured employee) is asked to re-enact in slow motion his/her actions which preceded the accident. 3.4.3 Accident/Incident Causation Analysis It is important to analyze an accident/incident to determine what cause or reason existed for the accident/incident to have occurred. In the most seemingly straightforward accident/incident, seldom, if ever, is there only a single cause.

9 - 11 To ensure that an effective accident/incident investigation is done it is important to look at all five key elements - Tasks, Materials, Environment, Personal and Management.

MATERIAL

TASK

ENVIRONMENT

MANAGEMENT PERSONAL

TASK Review the actual work procedure being used at the time of the accident/incident. Look for answers to questions such as: 1. Was a safe work procedure used? 2. Had conditions changed to make the normal procedures unsafe? 3. Were the appropriate tools, materials available? 4. Were they used? 5. Were safety devices working properly? 6. Was lockout used when necessary? For most of these questions, a vital subsequent question is "If not, why not?" MATERIAL To seek out possible causes brought about by the equipment and materials used, ask: 1. 2. 3. 4. 5. 6. 7. 8. 9. Was there an equipment failure? What caused it to fail? Was the equipment poorly designed? Were hazardous substances involved? Were they clearly identified? Was a less hazardous alternative substance possible and available? Was the raw material substandard in some way? Should personal protective equipment have been used? Was it used?

Again, each time the answer reveals an unsafe condition, ask why this situation was allowed to exist.

9 - 12 ENVIRONMENT The physical environment, and especially sudden changes to that environment, are factors which need to be identified. Note that it is the situation at the time of the accident/incident that is important. For example: 1. 2. 3. 4. 5. 6. What were the weather conditions? Was poor housekeeping a problem? Was it too hot or too cold? Was noise a problem? Was there adequate light? Were toxic gases, dust, fumes present?

PERSONAL The physical and mental condition of those directly involved in the accident/incident must be explored. Bear in mind that you are not investigating the accident/incident so that blame can be laid against someone; but your inquiry would not be complete unless you consider personal characteristics. Some factors will be more permanent; others may vary from day to day: 1. 2. 3. 4. 5. Were employees experienced in the work being done? Had they been adequately trained? Were they physically capable? What was the status of their health? Were they under stress (work or personal)?

MANAGEMENT Management holds the legal responsibility for the safety of the workplace and therefore the role of the Supervisor and higher management must always be considered in an accident/incident investigation. Answers to any of the preceding questions logically lead to further questions such as: 1. 2. 3. 4. 5. 6. 7. 8. Were safety rules in effect? Were they being enforced? Was adequate supervision given? Had hazards been previously identified? Had procedures been developed to overcome them? Were unsafe conditions corrected? Was regular maintenance of equipment carried out? Were regular safety inspections carried out?

Using this model as guide in accident/incident investigation prevents looking at facts in isolation and assists in trying to uncover all possible causes. While this checklist is only a sample of questions, other more pertinent questions can be asked to better focus on the true root cause. After analyzing the causes it is suggested you go back through the accident/incident step-by-step from the moment of the occurrence, listing the causes as they happened in each step. Note whether your conclusions are supported by direct evidence (physical or documented) or based on eyewitness accounts, or if it is based on assumptions. This serves as a final check on discrepancies which should be explained or eliminated. 3.4.4 Recommendations The final step is to come up with well considered recommendations designed to prevent recurrences of similar accidents/incidents. Make the recommendations as exact and specific as possible to address the causes found in the analysis.

DUFFERIN-PEEL CATHOLIC DISTRICT SCHOOL BOARD


INCIDENT INVESTIGATION REPORT A. INJURED EMPLOYEE IDENTIFICATION(FAX THIS FORM WITHIN 24 HRS. TO THE BENEFITS DEPARTMENT-905890-0421)
1. LAST NAME 2. FIRST NAME 3. WORK LOCATION 4. PRESENT OCCUPATION / YRS 5. DATE OF EMPLOYMENT D M

ADDRESS (NO., STREET, APT.) 6. EMPLOYEE #

CITY/TOWN

PROVINCE

POSTAL CODE

(AREA CODE) TELEPHONE

7. EMPLOYEE HOME PHONE #

8. FULL TIME PART TIME OCCASIONAL

9. NAME OF IMMEDIATE SUPERVISOR

B. INCIDENT DESCRIPTION Sequence of events leading to the incident (be specific)


10. INCIDENT LOCATION 11. DATE AND TIME OF INCIDENT AM PM 14. NAME OF WITNESS(ES) OR PERSON(S) HAVING KNOWLEDGE OF INCIDENT 12. DATE AND TIME REPORTED AM PM 15. RESULT OF INCIDENT (SEE OVER) FIRST AID MEDICAL AID LOST TIME MODIFIED WORK 16. NAME, ADDRESS, & TELEPHONE # OF PHYSICIAN 13. INCIDENT REPORTED TO WHOM

HAZARDOUS SITUATION DATE OF INJURY DATE OF VISIT

17. DESCRIBE THE WORKERS ACTIVITIES AT THE TIME OF INJURY/DISEASE. INCLUDE DETAILS OF EQUIPMENT OR MATERALS USED AND THE SIZE AND WEIGHT OF OBJECT BEING HANDLED:

18. TYPE OF INCIDENT (CHECK APPROPRIATE BOX) (SEE OVER) STRUCK OR CONTACT BY CONTACT WITH STUDENT OTHER (EXPLAIN) DESCRIPTION: SLIP/FALL STRUCK AGAINST/CONTACT WITH CAUGHT IN ON OR BETWEEN EXPOSURE OVEREXERTION SPORTS INJURY

19. PART OF BODY INJURED. DESCRIBE PART(S) OF BODY INJURED, INDICATING - RIGHT (R) OR LEFT (L) DESCRIPTION:

C. INCIDENT INVESTIGATION
20. WHAT CONDITION CONTRIBUTED TO THE INCIDENT ( ) CHECK THE APPROPRIATE BOX AND EXPLAIN CAUSES UNSAFE EQUIPMENT UNSAFE DESIGN OR ARRANGEMENT NOT GUARDED OR IMPROPERLY GUARDED UNSAFE POSITION OR POSTURE IMPROPERLY LABELLED OR IDENTIFIED EXPLANATION OF CAUSES: OPERATING WITHOUT AUTHORITY FAILURE TO SECURE OR WARN FAILURE TO USE PERSONAL PROTECTIVE DEVICE HAZARDOUS PERSONAL ATTIRE HAZARDOUS METHOD OR PROCEDURE FIRE OR EXPLOSION STUDENT ACTION IMPROPER VENTILATION SLIPPERY SURFACE OTHER (EXPLAIN)

21. ACTIONS TAKEN BY SUPERVISOR TO PREVENT RECURRENCE ( ) CHECK APPROPRIATE BOX REINSTRUCTION OF PERSON INVOLVED EQUIPMENT REPAIR OR REPLACEMENT CORRECTION OF CONGESTED AREA IMPROVE PERSONAL PROTECTIVE EQUIPMENT INSTALLATION OF GUARD OR SAFETY DEVICE ACTION TO IMPROVE DESIGN/PROCEDURE USE SAFER MATERIALS WORK ORDER SUBMITTED OTHER (EXPLAIN)

DESCRIBE ACTION TAKEN TO PREVENT RECURRENCE:

SIGNATURE OF SUPERVISOR

DATE OF REPORT

DATE ACTION TAKEN

The Supervisor is responsible to investigate the incident, to take corrective actions where applicable, to complete & sign the Incident Investigation Report and distribute within 24 hrs. 22. HEALTH AND SAFETY DEPARTMENT - COMMENTS (FOR HEALTH AND SAFETY DEPARTMENT USE ONLY)

SIGNATURE OF HEALTH AND SAFETY DEPARTMENT

DATE

MUNICIPAL FREEDOM OF INFORMATION AND PROTECTION OF PRIVACY ACT, 1989; INFORMATION ON THIS FORM IS CONFIDENTIAL PERSONAL INFORMATION COLLECTED ON THIS FORM WILL BE USED FOR THE PURPOSES OF: DETERMINING CAUSES OF ACCIDENTS, INCIDENTS, STATISTICS, DEVELOP PREVENTION PROGRAMMING AND GENERATING REPORTS. THIS INFORMATION IS COLLECTED UNDER THE LEGAL AUTHORITY OF THE OCCUPATIONAL HEALTH AND SAFETY ACT R.S.O. 1990 C. 0.1, 51 & S 10, 52 AND REGULATIONS FOR INDUSTRIAL ESTABLISHMENTS R.R.O. 1980 REG. 692 S.5. INQUIRES REGARDING THE COLLECTION OF THIS INFORMATIONS CAN BE DIRECTED TO: MANAGER OF HEALTH AND SAFETY - D.P.C.D.S.B. 40 MATHESON BOULEVARD WEST MISSISSAUGA, ONTARIO 905-890-0708

Distribute copies within 24 hrs. to:

White - Principal/Supervisor Pink - Health & Safety Department

Canary - Joint Health & Safety Committee Goldenrod Employee

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PURPOSE OF THE EMPLOYEE INCIDENT REPORT


Collect factual data relating to the occurrence of work injury. Collect data for completion of report to the W.S.I.B. to provide complete information on which to base a decision for payment. Provide a form on which to record, investigate and take corrective action on an incident. Ensure that corrective action is taken to eliminate recognized causative factors. Collect factual data to develop statistical records. Guide the investigator in making an effective investigation.

TYPE OF RESULTS Hazardous Situation An incident caused by an unsafe act, an unsafe condition or a combination of both in the work environment which could have resulted in property loss and/or physical harm. First Aid Injury An injury of such minor nature that treatment can be carried out by First-aider. Health Care (Medical Aid) Injury A work related incident, which requires medical treatment but does not result in time lost from work. Lost Time Injury A work-related injury, which results in time, lost from work beyond the day of the injury.

TYPES OF INCIDENT / DEFINITIONS OF CODES

1.

Struck or Contact By A struck or contact by incident is one in which a person has been contacted either abruptly and forcefully by some object in motion, (eg. Box falls off shelf, employee jabs needle into finger, person pushing cart runs into another person); or has been contacted non-forcefully by some substance or agent which has an injuryupon-contact characteristic, (eg. Employee is splashed by hot or corrosive solution). Struck against / contact with a struck against / contact with incident is one in which a person contacts either abruptly and forcefully, some object in his surroundings, (eg. Employee strikes leg against desk, person bumps head against cupboard door); or comes into contact non-forcefully with some substance or agent capable of producing injury on the basis of mere non-forceful contact (eg. electrical shock, hot pipe, employee places hand in scalding or corrosive liquid). Caught in, on or between a caught in, on, or between incident is one in which: a) a person is trapped in some type of enclosure, or a part of a persons body is caught fast in some type of opening, eg., a person is caught in an elevator, locked into a refrigerated room, shut into some type of vessel such as a boiler;

2.

3.

b)

c)

a person or some part of his clothing is caught on some protruding object, eg., person catches had on a sharp edge, catches loose clothing on a revolving spindle or on some protruding object; a person is pinched, crushed or otherwise caught between either a moving object and a stationary object or between two or more moving objects, eg., person jams fingers between wheeled cart and doorway, person catches arm in elevator door, jammed between loaded moving cart and a wall.

4.

Fall a fall incident can be subdivided into two categories a foot level fall or a fall to below. A slip or a trip should also be recorded under this category. A foot level fall occurs when a person slips or trips, eg. a person slips on a foreign matter on floor. A fall to below occurs when a person falls to below the level on which he was standing or walking, eg., a person falls from a ladder, window, chair or on stairs. Over-exertion / strain An over-exertion/strain incident is one in which a person put excessive strain on some part of his body, eg., employee strains his back or some other part of his body, eg., an employee strains back or some other part of his body lifting equipment, supplies, etc. Exposure An exposure incident is one in which the employee is exposed to harmful conditions; ie.; a) c) e) toxic gases, fumes or vapors; extremes of heat or cold; radioactive radiation; b) contagious conditions; oxygen deficient atmospheres; f) intense light brightness.

5.

6.

d)

For further Dufferin-Peel Catholic District School Board procedural information on Accident Investigation, refer to Section 9 of the Health and Safety Manual.