INCIDENT INVESTIGATION
OHS PROGRAM – CONSTRUCTION SAFETY
FORM #IIR-01 | REV. 01
SECTION 1 – EMPLOYER INFORMATION
Employer #1
Employer #2
Employer #3
SECTION 2 – INCIDENT/INVESTIGATION INFORMATION
SECTION 3 – DESCRIPTION OF THE INCIDENT
Injured Workers
| Name | Employer | Contact | Status |
|---|---|---|---|
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Others Involved
| Name | Employer | Contact | Relation |
|---|---|---|---|
PAGE 2 – INVESTIGATION & OUTCOMES
Interim Corrective Actions Taken
| Description of interim corrective action(s) | Due Date | By Whom | Completion Date |
|---|---|---|---|
Other Actions / Agencies Con
SECTION 5 – FULL INVESTIGATION
| Description of final corrective action(s) | Due Date | By Whom | Completion Date |
|---|---|---|---|
PAGE 3 – SECTION 6 – REVIEW
Injured Worker's Direct Supervisor
JOHS Committee/Worker Representative
Employer Representative/Manager
Safety Coordinator/Manager/Consultant
Site Superintendent/ CSO
Not selected