This form is to be completed by the Department Supervisor.

Section $1$: Information $($X$)$

Employee Involved in Incident:

Location $($specify name$)$:

Date of Incident:

Time: a$.$m$.$ p$.$m$.$

Job Title:

Location Where Incident Occurred:

Date Reported:

Time: a$.$m$.$ p$.$m$.$

Experience at this Job:

Date of Employment:

Date Reported to WSIB$/$: N$/$A

Section $3$: Risk Assessment $($X$)$

Likelihood Severity Risk Classification

Frequent

Probable

Occasional

Remote

Improbable Catastrophic

Critical

Marginal

Negligible High Risk

Serious Risk

Medium Risk

Low Risk

Section $5$: Describe How the Event Occurred

Attached: Documentation, Witnesses, Interviews, Photographs, Trainings records, Previous Disciplinary actions, etc

Section $6$: Interviews

Information from Interview: Statements Attached

Worker:

Supervisor:

Witness Other:

Other:

Yes No

Yes No

Yes No

Yes No

Yes No Name $\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_$

Name $\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_$

Name $\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_$

Name $\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_$ Name $\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_$

Section $7$: Immediate Causes $($see list on following pages$)$

List the immediate causes

$($Substandard Act or Conditions$)$

$($Choose from the list on following pages$)$ Explain

$1$

$2$

$3$

Section $8$: Basic Causes $($see list on following pages$)$

Immediate cause Basic causes Explain

$11\mathrm{.}1$

$1\mathrm{.}2$

$22\mathrm{.}1$

$2\mathrm{.}2$

$33\mathrm{.}1$

$3\mathrm{.}2$

Section $9$ Corrective Actio ns

ITEM # Action$($s$)$ to be Taken $($May address the basic causes$)$ Person$($s$)$ Responsible Target Date Completion Date

$1\mathrm{.}1$

$1\mathrm{.}2$

$2\mathrm{.}1$

$2\mathrm{.}2$

$3\mathrm{.}1$

$3\mathrm{.}2$

Section $10$: Approvals

Print Name Signature Date

Investigator $/$ Supervisor:

Manager:

Employee Involved:

Witness:

JH&SC Employee Rep.:

Other

IMMEDIATE CAUSES

Substandard Actions $($unsafe acts$)$: Substandard Conditions: $($unsafe conditions$)$

Failure to Secure $($machines$,$ tools$)$ Congestion$/$Restricted area $($housekeeping$)$

Failure to Use Proper PPE Poor Housekeeping

Failure to Use Tools Properly Ergonomics risk factors

Failure to Warn $($other employees$)$ Fire & Explosion Hazard

Horseplay Inadequate $/$ Improper PPE $($been supplied by the company$)$

Improper Lifting $($ergonomics$)$ Inadequate Guards$/$Barriers $($installed by the company$)$

Improper Loading $($machines$)$ Inadequate Illumination

Improper Placement $($for machines$)$ Inadequate Ventilation

Improper Position for Task $($for persons$)$ Inadequate warning system $($established by the company$)$

Improper Speed $($machines$)$ Inadequate$/$Defective Tools or Equipment $($provided by the company$)$

Making Devices Inoperable Too much noise

Operating Without Authority Radiation Exposure

Removing$/$Defeating Safety Devices Temperature Extremes

Servicing While Operating Other chemical and biological agents

Under the Influence $($drugs$,$ alcohol$)$ Other physical Agents

Using Defective Equipment

Using Equipment Improperly $($other reasons it was intended to be used$)$

BASIC CAUSES

Personal Factors Job Factors

Inadequate Physical $/$ Physiological Capability Abuse & Misuse

Improper Motivation Excessive $/$ Normal Wear & Tear $($of the equipment $/$ machines$)$

Inadequate Feedback $($provided$)$ Inadequate company$$s Engineering

Inadequate Leadership $/$ Supervision Inadequate company$$s Maintenance

Inadequate Mental $/$ Psychological Capability Inadequate company$$s Practice

Lack of Experience Inadequate company$$s Purchasing

Lack of Knowledge Inadequate company$$s Work Planning

Lack of Skill Inadequate company$$s Work Standards

Mental $/$ Psychological Stress $($too many demands$/$instructions that the person can handle$)$ Inadequate company$$s Instructions

Physical $/$ Physiological Stress