OHS Incident Report

This form must be completed for all incidents occurring in the workplace as soon as possible because reporting to safety authorities within strict timeframe might be required. We also want to prevent recurrence.

Name of injured and contact info / Status / Location of incident
(Base, building, office number...) / Date and time of incident
Employee
CF Member
Contractor
Public/Client
Volunteer
Date and time reported
Description of incident
Give accurate picture of the events leading up to the hazardous occurrence: What, When, Where, Why, How
First Aid Treatment Provided / Witness(as) and contact info
By whom:
Description:
Emergency Services / Medical Treatment by Health Care Professional
Ambulance Yes  No  Don’t know at this time
PoliceYes  No  Don’t know at this time
Fire Dpt.Yes  No  Don’t know at this time / Yes  No  Don’t know at this time 
ONLY IF EMPLOYEE - Select the severity as per definition below
Not work related(e.g. pre-existing medical condition) - No further action required
SEVERITY A – Serious
  • Death of an employee (even if it appears to be from natural causes);
  • Permanent disabling injury of an employee, or temporary disabling injury of two or more employees from the same occurrence;
  • Permanent impairment of a body function of an employee.
/ OR even if no injury is sustained
  • Explosion
  • Damage to a boiler that results in a fire or rupture of the boiler
  • Damage to an elevating device that renders it unusable

SEVERITY B – Moderate
  • Temporary disabling injuries
  • Loss of Consciousness: from an electric shock or a toxic or oxygen deficient atmosphere.
  • Rescue / Revival or other Emergency Procedure

SEVERITY C - Minor
  • Medical treatment provided by a health care professional, but excludes a disabling injury. (Medical treatment is that which is provided at a medical treatment facility, which means at a hospital, medical clinic or physician’s office at which emergency medical treatment can be dispensed and is not to be confused with first aid)

SEVERITY D – Slight
  • First Aid only

When you have determined the severity, consult FLOWCHARTfor the next steps. This is available on the online OHS toolbox (CFMWS.com: Home > Employee Zone > Human Resources > Occupational Health and Safety > Reporting Incidents)
The next steps are IMPERATIVE and TIME SENSITIVE as directed by Canada Labour Code part II and Government Employees Compensation Act
Name of Manager/Supervisor
filling this form
Printed / Signature / Phone Number

DISTRIBUTION

SLER -Senior Local Employer Representative (Action)

Local HR Office (Information)

Publication date: 2015-08-11Page 1 of 1

Last revision: 2016-09-23