Report an Incident or Close Call Form Completed By Date of Event Time of Event 121234567891011 : 0030 AMPM Reported Date What Happened Equipment Failure or Damage Close Call (no damage or injury) Injury or Illness Motor Vehicle Incident (MVA) Property Damage Security Dangerous Goods Spill Fire Description Include the details of what happened before, during, and after the event. Describe who was involved, the job being performed, and where the incident took place. Immediate Action List any actions taken immediately after the incident up until now. (eg. first aid treatment, scene secured, called ambulance) Occurred on Worksite Yes No Specific Location (eg. Hwy #, project site) Person Injured or Involved Person Injured or Involved First First Last Last Role of Person Involved Employee Contractor Other Severity Level Level 1 Low (first aid only, no days missed, damage < $1K)|Level 1 Low (first aid only, no days missed, damage < $1K) Level 2 Medium (clinic, hospital, doctor, dentist, days missed, damage $10K-100K) Level 3 High (hospital stay, loss of consciousness, fractures, damage over $100K) Level 4 Catastrophic (1 or more fatalities) *If this is a Close Call (NO injury or damage but WOW that was close) then select the level that describes the likeliest outcome had impact or contact occurred. Contributing Factors Job Factors (problem with training, tooling, or equipment) Personal Factors (tired, rushing, unaware of hazard) System Deficiencies (no training, no procedures, no process) Unsafe Acts (took a risk knowingly) Unsafe Conditions (weather, poor housekeeping) *The unsafe conditions, acts, or procedure that contributed to the event. List any other possible causes Preventative Actions Create preventative actions for each identified cause & assign to the person(s) responsible. More than one action per cause is ok. Action Assigned To Due Date Add Remove Treatment Provided First Aid Attendant Hospital, Clinic, Doctor, Dentist, RMT, Physio, Chiro If Hospital, Clinic, Doctor, Dentist, RMT, Physio, Chiro is selected please complete the WSBC Investigation Report. Witnesses Include anybody who can provide factual information of the time leading up to, during, and after the event. Name Contact Information Add Remove Captcha If you are human, leave this field blank.
