Incident investigation and Reports.

 

This assignment can be done individually or in pairs. The purpose of this assignment is for you to demonstrate your knowledge of Incident investigation and Reports. Take the time to demonstrate your knowledge. 

1. You will be given the name of a video that can be accessed from the Workplace Health and Safety Course Moodle site.

2. You are to complete the incident investigation summary report using the format provided. Remember this is a professional document and it will form the basis for the permanent record of this incident. Appropriate care must be taken when completing the document.

3. The video provides the factual basis for your summary report, for all other information needed to complete the report; you are to provide a reasonable assumption/hypothesis as to that information. 

4. The grading rubric is attached.

Assignment #3 Rubric

Incident Investigation and Report

	Excellent (8.0)	Good  (7.0-5.0)	Fair (4.0-3.0)	Poor (2.0-1.0)	Unacceptable (0.0)
Content (8.0 pts max.)	Content is comprehensive Responses are accurate and based on the material Responses/ conclusions demonstrate understanding of concepts	Content is comprehensive most of the time Responses/ conclusions are accurate and based on the material Most or all responses/ conclusions demonstrate understanding of concepts	Content is comprehensive only some of the time Most responses are accurate and based on the material Responses/ conclusions are sometimes inadequate, but demonstrate some understanding of concepts	Content is not comprehensive Most/all responses are unclear or inadequate Responses/ conclusions often do not address the material Unclear if most concept are understood	Content is not comprehensive Most/all responses unclear or include irrelevant information Responses/ conclusions do not address the material
	Excellent (5.0)	Good  (4.0-3.0)	Fair (2.0)	Poor (1.0)	Unacceptable (0.0)
Organization & Structure (5.0 pts max)	Structure is clear and easy to follow Sentences and paragraphs are always logically organized In keeping with the creation of a professional permanent record Proper format	Structure is mostly clear and easy to follow Sentences and paragraphs are mostly logically organized  Mostly in keeping with the creation of a professional permanent record Proper format	Structure is not always easy to follow Sentences or paragraphs sometimes lack logical organization Somewhat lacking in the professionalism of a  permanent record Proper format or only minor issue with format	Structure often hard to follow Sentences or paragraphs frequently not logically organized Mostly lacking in the professionalism of a professional permanent record Improper format	Structure difficult to follow Most sentences or paragraphs not logically organized Unprofessional, not in keeping with a  permanent record Improper format
	Excellent (2.0)	Good  (1.5)	Fair (1.0)	Poor (0.5)	Unacceptable (0.0)
Spelling & Grammar (2.0 pts max)	No obvious errors or irregularities	3 or less errors or minor irregularities	4 or less errors or minor irregularities	5 or less errors or major irregularities	5 or more errors or major irregularities

WORKPLACE SAFETY AND HEALTH COMMITTEE

INCIDENT INVESTIGATION SUMMARY REPORT

      Industrial  ⃝                                    Construction   ⃝                                  Service Sector  ⃝

Employer Name: ______________________________________________________________________

Department/Location:__________________________________________________________________

Address:_____________________________________________________________________________

 

____________________________________________________________________________________

INJURY:     YES    ⃝         NO   ⃝

DATE and TIME of INCIDENT: ______________________________________________________

INVESTIGATING COMMITTEE MEMBERS:

__________________________________________________________

__________________________________________________________

___________________________________________________________

PART I – PARTICULARS

Did the incident involve injury?

If yes,

Name of the injured: ____________________________________________________________

                                                  First Name                                Middle                                        Last Name

Injured Worker’s Home Address: __________________________________________________________

___________________________________________________________

___________________________________Postal Code______________

Telephone:_________________________________________________

                          Cellular                                        Land line

Supervisor’s Name:_____________________________________________________________________

                                             First Name                                  Middle                                       Last Name

Physical Location of Incident:_____________________________________________________________

Injury

⃝  Lost Time ⃝  Medical Aid    ⃝  First aid   ⃝  Hazardous condition, no injury

Causes (check all that apply) 

⃝   unsafe act     ⃝   unsafe condition   ⃝   poor/damaged equipment    ⃝   no/poor training   

⃝   no/poor procedures    ⃝   other 

Explain the Nature of the Injury: __________________________________________________________

_____________________________________________________________________________________

Accident type 

⃝   overexertion/strain     ⃝   caught in/between   ⃝   slip/fall    ⃝   struck by/against   ⃝   exposed to    ⃝   motor vehicle    ⃝   contact with/by     ⃝   other   

Explain

Injury type 

⃝   bruise     ⃝   burn (heat)    ⃝   burn (chemical)     ⃝   cut    ⃝   crush    ⃝   strain    ⃝   twist     

⃝   lift           ⃝   electric shock     ⃝   inhalation    ⃝   occupational illness     ⃝   rash    ⃝   other        

Explain

Part of body injured ⃝ left ⃝ right 

⃝   head ⃝   face ⃝   eye ⃝  ear ⃝   neck ⃝   chest    

⃝   lung ⃝   abdomen ⃝   groin ⃝   back-upper ⃝   back middle ⃝   back lower

⃝   buttock ⃝   shoulder ⃝   arm ⃝   wrist ⃝   hand ⃝   finger th 2 3 4 5  

⃝   leg ⃝   knee ⃝   ankle ⃝   foot ⃝   toe big 2 3 4 5   ⃝   other        

Explain

Did the incident involve property damage? YES   ⃝ No   ⃝

If yes, describe:

Was first aid rendered? YES   ⃝ No   ⃝

If yes, by whom?

External Medical Assistance

Name & address of hospital or clinic

Name of attending doctor

Name of family doctor

Address

Date and hour last worked

Shift information         ⃝  Day ⃝  Afternoon ⃝  Midnight

PART II – DESCRIPTION OF THE INCIDENT

PART III – EVIDENCE

Sketch of incident scene:

Describe physical evidence collected:

Photo/Video Evidence: (List and describe the photos and videos)

PART III – EVIDENCE (CONTINUED)

Persons with information – Statement Summary:

Witness Name:

Does the witness have knowledge of the accident/incident or injury? YES   ⃝    No   ⃝

Did the witness see the accident/incident or injury? YES   ⃝     No   ⃝

Knowledge of accident/incident/injury: Explain what you know about the accident/incident/injury (e.g. what type of work was being done at the time of the accident/incident/injury, what happened to cause the accident/incident/injury, how serious was the injured worker hurt).

 What the witness actually saw: Please identify what you saw before the accident/incident/injury, during and immediately after.

Give your opinion as to how this accident/incident/injury could have been prevented.

Witness Signature: Date:

PART III – EVIDENCE (CONTINUED)

Persons with information – Statement Summary:

Witness Name:

Does the witness have knowledge of the accident/incident or injury? YES   ⃝    No   ⃝

Did the witness see the accident/incident or injury? YES   ⃝     No   ⃝

Knowledge of accident/incident/injury: Explain what you know about the accident/incident/injury (e.g. what type of work was being done at the time of the accident/incident/injury, what happened to cause the accident/incident/injury, how serious was the injured worker hurt).

 What the witness actually saw: Please identify what you saw before the accident/incident/injury, during and immediately after.

Give your opinion as to how this accident/incident/injury could have been prevented.

Witness Signature: Date:

PART IV – INCIDENT CAUSATION

What was the DIRECT CAUSE of the incident? (What caused injury or damage?)

What are the INDIRECT CAUSES?  (What caused the incident?)

Task:

Worker(s):

Material/Equipment:

Management:

Environment:

PART V – CORRECTIVE ACTION:

Immediate corrective actions to prevent recurrence:

Target Date for corrective action:

dd/mm/yy

Long term solutions:

Target Date for corrective action:

dd/mm/yy

PART VI – REPORT REVIEW

Signature of Investigator(s):

                                                   

Date report completed:

dd/mm/yy

Distribute report to:

Signatures of Co-Chairpersons – Safety and Health Committee:

_________________________________ __________________________________________

     Employer Co-chair/           Date       Worker Co-Chair/                    Date