CONTRACTOR MONTHLY SAFETY REPORT

Company Name:
Project
Name/Location:

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Project Start Date:

Incidents
Near Miss (NM)
First Aid (FA)
Medical Aid (MA)
Property Damage (PD)
Lost Time Incidents
(LTI)

TOTAL CASES

Total
Employee
s:

to choose date.
This
Month
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Total

Trips, Slips or Falls

Eye Injuries
Falling Objects
Material Handling

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Month
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Total
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Others:
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TOTAL CASES

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here.
No. Safety
Meeting(s
):

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Number

Cause of Injuries

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choose a date.

Finish

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Number

Have all employees on site attended a safety orientation?

No.
Orientations
this Month:
Yes

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Number

No

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

Enter Name .
Completed by
Contractor

date.
Date

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Reviewed by

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Project Safety Coordinator

date
Date

date.
Date

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U of A Project Manager

date
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.

SEND THE COMPLETED REPORT TO

Facilities and Operations Safety Division

Fax (780) 492-9692 or e-mail

(Copy to the University of Alberta Project Manager)

fosafety@ualberta.ca
ContractorSafety/257448946

Revised: March 2014

CONTRACTOR MONTHLY SAFETY REPORT

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

Fax (780) 492-9692 or e-mail

(Copy to the University of Alberta Project Manager)

fosafety@ualberta.ca
ContractorSafety/257448946

Revised: March 2014