INCIDENT INVESTIGATION
OHS PROGRAM – CONSTRUCTION SAFETY
FORM #IIR-01 | REV. 01
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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
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
PHOTOS / ATTACHMENTS