The Employee Incident Report Form is a mandatory document required under Canadian occupational health and safety legislation for recording and reporting workplace incidents, injuries, and near-misses. This form must be completed whenever a workplace incident occurs, whether resulting in injury or not, and serves as an official record for regulatory compliance, insurance purposes, and internal safety management. The document supports employers' obligations under provincial Workers' Compensation Acts and the Canada Labour Code, while also providing essential documentation for workplace safety initiatives and incident prevention programs. It facilitates proper incident investigation, helps identify workplace hazards, and supports the development of corrective actions to prevent future occurrences.
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1. Incident Identification: Basic information including date, time, location of incident, and report completion details
2. Employee Information: Details of affected employee(s) including name, employee ID, department, job title, and immediate supervisor
3. Incident Details: Comprehensive description of what happened, including sequence of events and immediate response taken
4. Injury/Damage Information: Nature and extent of any injuries or property damage that occurred
5. Witness Information: Names and contact details of any witnesses to the incident
6. Immediate Actions Taken: Description of emergency response, first aid, or other immediate actions taken following the incident
7. Initial Assessment: Preliminary evaluation of incident severity and potential causes
8. Reporting Information: Details of when and to whom the incident was reported, including external authorities if applicable
9. Verification: Signatures and dates from employee, supervisor, and safety representative confirming report accuracy
1. Vehicle Incident Details: Additional section for incidents involving company or personal vehicles, including insurance information
2. Hazardous Materials: Specific section for incidents involving dangerous goods or hazardous materials
3. Equipment/Machinery Involvement: Detailed section for incidents involving equipment malfunction or machinery
4. Environmental Impact: Section for incidents with potential environmental consequences
5. Third Party Involvement: Additional details when non-employees are involved in the incident
6. Remote Work Considerations: Special section for incidents occurring during remote work arrangements
1. Appendix A - Incident Scene Diagram: Template for sketching the incident scene and relevant details
2. Appendix B - Photographic Evidence Log: Form for cataloging and describing any photographs taken of the incident scene
3. Appendix C - Witness Statement Form: Standard template for collecting detailed witness accounts
4. Appendix D - Medical Assessment Form: Template for recording initial medical evaluation if applicable
5. Appendix E - Property Damage Assessment: Detailed form for documenting property damage
6. Schedule 1 - Investigation Checklist: Standardized checklist for ensuring thorough incident investigation
7. Schedule 2 - Regulatory Reporting Requirements: Reference guide for determining external reporting obligations
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