Employer Incident Investigation Report (Preliminary)

Preliminary Investigation
Have you received and Incident ID # form this incident (ie: First Aid Report)?*
- Yes
- No
Incident ID #*
School District*
District Health and Safety Rep Email*
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Report Date
MM slash DD slash YYYY
School/Location*
Date of incident*
MM slash DD slash YYYY
Time of incident*

: Hours

Minutes

AM/PM
Worker's Name*
First Last
Employee Number*
Position*
Incident Type*
- Workplace Accident
- Reportable Behaviour
- Violent Incident
Injury Type*
- Near Miss
- Injury/illness
- Gradual onset

Injury/Illness Information
Cause*
Source*
Primary Injury*
Nature of Primary Injury*
Secondary Injury
Nature of Secondary Injury
Other injuries
Witnesses and others with relevant information
Name Relation/Position
Did the worker receive first aid?*
- Yes
- No
Treatment Date*
MM slash DD slash YYYY
Will the worker be seeking medical attention (now or in the near future)?*
- Yes
- No
Will the worker be missing time from work BEYOND the day of injury?*
- Yes
- No

Incident Causes and Corrective Measures
Statement of the sequence of events that preceded the incident*
Worker reported:
Brief description of the incident*
Worker reported:
Interim Corrective Action Report
Identification of any unsafe conditions, acts or procedures that significantly contributed to the incident*
Interim corrective actions to prevent the recurrence of similar incidents until full investigation is completed*
Who will act*
First Last Job Titlie
Date action taken*
MM slash DD slash YYYY
Are there any other persons actively involved in the accident or incident, or persons implementing the corrective action*
- Yes
- No
Other involved in the full investigation
Name Job Title
Are there any circumstances of the accident or incident that preclude you from addressing a particular element of the incident during the preliminary investigation period.?*
- Yes
- No
Please explain the circumstances
Name of investigator (Preliminary Report)*
First Last Job Titile
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User Email*
Name of Worker Rep (Preliminary Report)*
First Last Job Title
Worker Rep Email*
Are there any additional or underlying causes to this incident that have not been identified in the Preliminary Investigation or any additional corrective measures that need to be taken to prevent a similar incident in the future??*
- Yes
- No

Preliminary Investigation

Name	Relation/Position

Name	Job Title