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Metro Home Building Centre – Staff
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    • Section 02
      • Disciplinary Warning Notice Form
      • Manager Safety Performance Review
      • Supervisor Safety Performance Review
      • Employee Safety Performance Review
    • Section 04
      • Bomb Threat / Anonymous Telephone Call Record
      • Fall Arrest System Inspection Form
      • Emergency Response Plan for Employees Requiring Accommodations
      • Harassment Incident Report Form
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      • Hot Work Permit
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    • Section 05
      • Annual Safety Committee Meeting Schedule
      • Safety Committee Meeting Minutes
      • Safety Committees Recommendations to Employer Form
    • Section 06
      • Orientation Checklist
      • Employee Information Form
      • Direct Deposit Agreement Form
      • TD1 – Personal Tax Credits Return
    • Section 07
      • First Aid Treatment Record
      • Refusal of Treatment or Refusal to be Transported to The Hospital Statement
    • Section 08
      • Ladder Inspection Checklist
      • Quarterly Workplace Inspection Checklist
      • Workplace Inspection Report Form
    • Section 10
      • Accident / Incident Investigation Report
      • Accident / Incident Investigation Employee’s Statement
      • Accident / Incident Investigation Witness Statement
    • Section 12
      • Return to Work Plan Monitoring Form
      • Exit Program Form – Injury Management and Return to Work
      • Return to Work Plan
  • Benefits
  • Online Training
  • Metro Home
  • Staff Home
  • Safety
    • Policies
    • Government Regulations
    • Meeting Minutes
    • Inspection Reports
    • Inspection Certificates
    • Guides
    • Posters
    • Responsibilities
  • Vacation Tracker
  • Vacation Board
  • Forms
    • Section 02
      • Disciplinary Warning Notice Form
      • Manager Safety Performance Review
      • Supervisor Safety Performance Review
      • Employee Safety Performance Review
    • Section 04
      • Bomb Threat / Anonymous Telephone Call Record
      • Fall Arrest System Inspection Form
      • Emergency Response Plan for Employees Requiring Accommodations
      • Harassment Incident Report Form
      • Hazard Report Form
      • Hot Work Permit
      • Housekeeping Inspection Form
      • Illness/Injury Reporting Form
      • Lockout Add
      • Lockout Removal
      • Non-Routine Work Form
      • Violence Incident Report Form
      • Work Refusal Form
      • Spill Report Form
    • Section 05
      • Annual Safety Committee Meeting Schedule
      • Safety Committee Meeting Minutes
      • Safety Committees Recommendations to Employer Form
    • Section 06
      • Orientation Checklist
      • Employee Information Form
      • Direct Deposit Agreement Form
      • TD1 – Personal Tax Credits Return
    • Section 07
      • First Aid Treatment Record
      • Refusal of Treatment or Refusal to be Transported to The Hospital Statement
    • Section 08
      • Ladder Inspection Checklist
      • Quarterly Workplace Inspection Checklist
      • Workplace Inspection Report Form
    • Section 10
      • Accident / Incident Investigation Report
      • Accident / Incident Investigation Employee’s Statement
      • Accident / Incident Investigation Witness Statement
    • Section 12
      • Return to Work Plan Monitoring Form
      • Exit Program Form – Injury Management and Return to Work
      • Return to Work Plan
  • Benefits
  • Online Training

Accident / Incident Investigation Report

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Accident / Incident Investigation Report

Type of Investigation(Required)
Injured/Affected Party’s Name(Required)
Person Involved
Date of Accident/Incident(Required)
Time
:
Date Reported
Time Reported
:
Immediate Supervisor
Date of Investigation
Name of Investigator
Medical attention provided
Was this their regular job?
Overtime?
(Work centre, specific workstation, parking lot, etc.)
Area of Injury
(Please check all that apply)
Cause of Injury
Check all that apply
Type of Injury
Check all that apply
Cause of Accident
Check all that apply
Medical Status
Check all that apply
Employee Status
Check all that apply
Action(s) to Prevent Recurrence
Recommendation
Action
Assigned To
Expected Completion Date
Status
 
Name(Required)
By entering your name or initials, you affirm your identity and agree to the information provided above.
Date(Required)
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