University of Victoria

INCIDENT INVESTIGATION REPORT

Incidents include both reportable accidents and near misses. This form is to be completed by an employee and an employer representative and returned to the Occupational Health and Safety Office (Sedgewick B127 or Fax 6359). Detailed information on incident investigations is available at http://ohs.uvic.ca/wcb/index.html, or if you have further questions, call OHS at 8971

Incident Type:

Near miss

Accident with no injury

Accident with injury ______

(ensure all injuries are reported in the Departmental Accident Record Book)

Name of Employee(s):

__ Date of Investigation:

Date of Incident: ________________, 20 __ Time:___________ Location:__ ___ _____________ 1 Doctor (own physician, clinic, hospital, etc.) Treatment: 1 None or N/A 1 First Aid by Campus Security Witnesses: _______ Telephone: ____ Interviewed: 1 Yes 1 No _______ Telephone: ____ Interviewed: 1 Yes 1 No Note: Attach additional sheet if more space is needed Description of Incident: (if applicable, include details of any injuries)

Incident Causes & Contributing Factors: (unsafe environment, condition, improper procedure, unsafe act, personal factor)

Corrective Measures: (measures taken and / or recommended to prevent a recurrence of this and
similar incidents)

Referred to:

____
Employer Representative Job Title

________
Signature

____
Date

__ __
Date

____
Employee Representative Job Title

________
Signature

____

University of Victoria

A GUIDE TO INCIDENT INVESTIGATIONS

An incident is an accident or other occurrence which resulted in or had the potential for causing an injury or occupational disease. Incidents include a(n): Near-miss (an incident that caused no visible injury or damage but that could have resulted in a serious injury, or property damage) Accident in which no one is injured but equipment or property is damaged Accident in which an employee is injured Purpose of an Incident Investigation An incident investigation should answer the questions: WHO, WHERE, WHEN, WHAT, WHY and HOW This Incident Investigation collects information that answers: WHO Name of injured employee, other person(s) involved WHERE Location of the incident WHEN Date and time of incident Description of the incident will answer: WHAT Before the incident: o What happened before the incident? o What were the events that led up to the incident? o What was the employee doing shortly prior to the incident? At the time of the incident: o What happened at the time of the incident? o What was the employee doing at the time of the incident? o What was the last event before the employee got injured?

After the incident: o What happened after the incident? o Who was involved? o What treatment, if any, was given to the injured employee? Other information: o Other observations o Other related information

Incident Cause(s) and Contributing Factor(s): WHY From the WHAT, you should be able to identify the hazard(s) that the employee was exposed to and thus WHY the incident occurred. To determine the most probable cause(s) and contributing factor(s), consider details of the investigation and,where possible, the employees statement. Determine if the incident was due to an ACT of an individual, a CONDITION of the working environment, or a PERSONAL FACTOR inherent in an individual at the time of the incident. Unsafe Act: A specific action or lack of action by an individual which would be considered under the individuals control. Generally, violation of safety rules or disregard of hazard would be considered unsafe acts unless specific criteria indicated a personal factor to be in the cause. Examples include: o Abuse of equipment, willful misconduct o Jumping from elevation o Not following established rules Unsafe Environment or Condition: A situation or event not controllable by the individual. Inadequate training or instruction should be considered a condition as opposed to a deficiency in skill or ability. Examples include: o Orientation training lacking or inadequate o Personal protective equipment not available o Poor housekeeping, congested area o Failure of equipment, tool Personal Factors: Where there is evidence of a deficiency in ability, physical condition or mental attitude; an uncontrollable factor inherent in an individual at the time of the incident. Examples include: o Work fatigue due to manual exertion o Illness or Allergy o Language difficulties Corrective measure(s) section will answer: HOW Once you know WHY an incident occurred, you can now determine HOW to prevent recurrence of this and similar incidents. Examples include: o Action to improve design or construction o Establish or revise safe work procedure o Assigning additional help o Order use of safer material(s) o Equipment/building repair or replacement o Training/retraining of person(s)