Community Head Injury Resource Services (CHIRS)
INVESTIGATION REPORT
To be completed by Service Coordinator/Manager.
A: Summary of Original Reports / Check ‘√’ applicable report(s): Employee Incident Report / Hazard Report
Type of Incident: / Type of Hazard:
See Employee Incident Report,B: Description of Incident / See Hazard Report, D: Hazard Classification
Report Submitted by: / Report Submitted by:
Date of Report: / ( _ _ / _ _ / _ _ ) / Time of Day: / Date of Report: / ( _ _ / _ _ / _ _ ) / Time of Day:
(DD/MM/YY) / am/pm
Program/ Department: / Program/ Department:
Client Incident Report / Record of Client Complaint
Type of Incident: / Type of Complaint:
See Client Incident Report, A: General Information / See Record of Client Complaint, B: Description of Complaint
Client Name & I.D.#: / Client Name & I.D. #:
Report Submitted by: / Report Submitted by:
Date of Report: / ( _ _ / _ _ / _ _ ) / Time of Day: / Date of Report: / ( _ _ / _ _ / _ _ )
(DD/MM/YY) / am/pm / (DD/MM/YY)
Program/ Department: / Program/ Department:
Description of Report(s)/Record (summarize the information contained in the original report(s)/record):
Investigation Details (describe investigative steps taken (e.g. survey of scene, employee/client interviews); note additional information not recorded in original documentation but discovered during course of investigation):
B: Root Cause Analysis / Check off ‘√’ all applicable root causes
Unsafe Acts / Unsafe Conditions / Systems Deficiencies
Failure to Identify/Correct Hazard / Poor workstation design/layout / Lack of written procedures/policies
Failure to follow directive / Congested Work Area / Safety rules not enforced
Improper PPE / PPE not used / Hazardous substances / Hazards not corrected
Operating equipment without training / Fire/ Explosion Hazard / PPE unavailable
Failure to warn or secure / Inadequate Ventilation / Insufficient Worker training
Operating at Improper speeds / Improper Material Storage / Insufficient supervisor training
By-passing safety practices / Proper Tool/Equipment not available / Staff Fatigue
Unnecessary haste/ inattention / Insufficient knowledge of job / Inadequate supervision
Horseplay / Poor weather conditions / Inadequate job planning
Improper Lifting / Poor housekeeping / Inadequate hiring practices
Drug or alcohol use / Excessive Noise / Inadequate workplace inspection
Unsafe act of others / Fumes, gas, dust, vapour involved / Inadequate equipment
Failure to follow established procedures / Defective Equipment / Unsafe design or construction
Equipment used improperly / Extreme Temperatures / Scheduling Issues
Failure to use proper equipment / Insufficient Lighting / Poor Procedure design
Client Behaviour / Change in Level of Client Function / Unresolved Client Issue (clinical, physical)
Workplace Violence / Medical Issue / Lack of Equipment Maintenance
Failure to check equipment prior to operation / Poor Surface Conditions / Other:
Short Cut used / Confined space
C: Incident/ HazardAnalysis / Using the root cause analysis list, record the ‘root causes’ identified and provide specific details relating the root cause to the reported incident or hazard.
Root Cause: / Specific Issue Identified:
D: Corrective Action / Describe specifically actions that will be taken to prevent recurrence of incident, accident, near miss; protect employees from identified hazard; correct hazardous conditions:
Action / Deadline / Person Responsible / Date Completed
( _ _ / _ _ / _ _ ) / ( _ _ / _ _ / _ _ )
(DD/MM/YY) / (DD/MM/YY)
( _ _ / _ _ / _ _ ) / ( _ _ / _ _ / _ _ )
(DD/MM/YY) / (DD/MM/YY)
( _ _ / _ _ / _ _ ) / ( _ _ / _ _ / _ _ )
(DD/MM/YY) / (DD/MM/YY)
E: Communication / Employees Notified of Incident/ Hazard (as applicable):
Indicate with a ‘√’ how information was communicated / Date: / ( _ _ / _ _ / _ _ )
Voicemail / Team Meeting / Posted Memo / (DD/MM/YY)
Investigation outcomes reviewed with Employee who submitted report: / Date: / ( _ _ / _ _ / _ _ )
Yes / No / (DD/MM/YY)
Employees Notified of Investigation Outcomes (as applicable):
Indicate with a ‘√’ how information was communicated / Date: / ( _ _ / _ _ / _ _ )
Voicemail / Team Meeting / Posted Memo / (DD/MM/YY)
Investigation Completed by:
Service Coordinator/ Manager Name (Please Print) / Signature / Date
Report Reviewed by:
Manager/ Program Director Name (Please Print) / Signature / Date
To be completed by Manager/Program Director reviewing report:
Distribution List: Indicate which staff REQUIRE this report (have not yet received a copy). Check all applicable and forward form to ExecutiveAssistant (or if Investigation is related to a Client Incident Report, then forward form to Administrative Assistant).
Program Director
Privacy Officer / Clinical Director
JHSC Worker Representative / CPI Instructor
Supervisor / Executive Director (Required for potential adverse events)
To be completed by Administrative/Executive Assistant:
Forms Distributed List: Indicate which staff have received a copy of this report.
Program Director
Privacy Officer / Clinical Director
JHSC Worker Representative / CPI Instructor
Supervisor / Executive Director (Required for potential adverse events)
Executive Director Review / To be completed by theExecutive Directorif investigation findings indicate that the incident is potentially an adverse event.
Adverse Event - An unexpected incident caused by system deficiencies or the actions of an employee which results in a client injury, impairment, hospital admission, or death and is not attributed to the clients underlying medical condition. / Yes / No
Comments:
Executive Director Name (Please Print) / Signature / Date
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ADM-14 Investigation Report
Last revised November 29, 2007