Incident Report Form - Department of Physics - Ryerson University

More documents

Recommendations

Info

Ryerson University AIE Internal Report Page 2 of 4FOR SUPERVISOR TO FILL OUT OR THEIR DESIGNATEDESCRIBE HOW THE EVENT OCCURREDDescribe the sequence of events leading up to the incident,WHERE the incident occurred, WHAT theperson was doing at the time, and the SIZE, TYPE and WEIGHT of equipment or materials involved:KEEP IN MIND THE FOLLOWING CONTRIBUTING FACTORS:People Equipment Materials Environment ProcessIMMEDIATE CAUSES:What Substandard Acts/Practices and Conditions caused orcould have caused the event? Please use checklist on Page 4 and explain here.BASIC CAUSES:What Specific Personal or Job/System Factors caused or could have caused this event?Please use checklist on Page 4 and explain here.Centre for EHS ManagementFile: UEHS_FM_001_2008.xls
Ryerson University AIE Internal Report Page 3 of 4OUTLINE WHAT ACTIONS HAVE BEEN DONE AND SHOULDBE DONE TO PREVENT SIMILAR ACCIDENTSACTIONS TO PREVENT INCIDENT RECURRENCE(check those actions taken to prevent recurrence, mark with a "P" other corrective actions decided upon but no yet taken):Administration Personal Protective EquipmentLeadership Training Health and Hygiene ControlPlanned Inspections and MaintenanceTask Analysis and ProceduresSystem EvalulationEngineering and ChangeAccident/Incident Procedures Personal CommunicationsTask Observation Group CommunicationsEmergency Preparedness General PromotionRules and Work Permits Hiring and PlacementAccident/Incident Analysis Materials and Services ManagementKnowledge and Skill TrainingOff-the-Job SafetySupervisor Comments:LIST SPECIFIC ACTIONS TAKEN BY YOU as the Supervisor. PROVIDE any additionalinformation that may help with the PREVENTION OF AN ACCIDENT of the same or similar natureSupervisor's SignatureDATE: (day/month/year)C h e c k l i s t: (REVIEW AND MARK)Reviewed by Supervisor (Principal Investigator / Coordinator / Manager / Chair / Director / Dean)Recommendations MadeActions TakenWSIB Employer's Report Form 7 filled out (for employees only) and ORIGINAL sent to HR -- copy kept in department fileOriginal Internal AIE Report sent to CEHSMCopy of Internal AIE Report provided to employeeCopy of Internal AIE Report made for Department FileCopy of Internal AIE Report provided to appropriate LOCAL UNION OFFICE at RyersonIF THERE IS AN INJURY OR MEDICAL ATTENTION IS PROVIDED as per s.52(1) OHSADEPARTMENTAL SAFETY OFFICER (DSO) COMMENTS:DSO's NAME:DATE REVIEWED:Centre for EHS ManagementFile: UEHS_FM_001_2008.xls
Page 1: Ryerson University AIE Internal Rep

Incident Report Form - Department of Physics - Ryerson University

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?