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I � i ATTACHMENT 3b INCIDENT INVESTIGATION/NEAR MISS INVESTIGATION REPORT i Incident Investigation./ Near-Miss Investigation Report j 9 Consider using the Root Cause Analysis PROACTIVELY to avoid incidents and near misses. INCIDENT TYPE (To be filled in by Human Resources Department) Date of incident: ❑ Fatality ❑ ...Industrial Non-Recordable ❑ Spill/Leak ❑ General Liability ❑ Lost Workday ❑ Non-Industrial ❑ Product Integrity ❑ Criminal Activity ❑ LW Restricted Duty ❑ Off-the-Job Injury ❑ Equipment ❑ Notice of Violation ❑ OSHA Medical or Illness wlo LW ❑ MVA ❑ Business Interruption ❑ Near Miss ff ❑ First Aid ❑ Fire The STANTEC Project Manager, Human Resources and Corporate Health&Safety must be informed immediately after stabilizing the victim(s)Isile as the result of an incident or near miss. The investigation of the incident or near miss by the employee's supervisor or Site Health and Safety Officer must also , begin immediately. This report must be completed as soon as possible, in most cases within the week of the incident. It must be reviewed and signed by I the Principal and e-mailed or faxed to the Vice President of Human Resources,and Corporate Health and Safety(numbers at end),even if employee is not E available to review and sign. Employee or employee's doctor must submit a copy of the doctor's report to Human Resources within 24 hours of the initial exam and any subsequent exams. Contact information at end of report. EMPLOYER (include sub-contractors, or other employers on our sites) Company Name: i I ' Work Location Address where incident occurred: Project Name:- ' EMPLOYEE r ` Name: --------- ---......... _ -- — Employment Status: ❑Full-Time ❑ Part-Time ❑Hourly-As-Needed How long in present job? � INJURY OR ILLNESS INFO r Where did incident!near miss occur? (number,street,city,state,zip): .. County: On Employer's premises?❑Yes ❑ No Specific activity the employee was engaged in when the incident 1 near miss occurred: All equipment,materials,or chemicals the employee was using when the incident I near miss occurred(e.g.,the machine employee struck against or which Ih struck employee;the vapor inhaled or material swallowed;what the employee was lifting,pulling,etc.): Describe the specific injury or illness(e.g.,cut,strain,fracture,skin rash,etc.): < Body part(s)affected(e.g.,back,left wrist,right eye,etc.): Name and address of Health Care Provider(e.g.,physician or clinic): Phone No.: If hospitalized,name and address of hospital: Phone No.: Date of injury or onset of illness(MMIDDIYYYY) I 1 Time of event or exposure:❑AM ❑ PM t ------------- -- --- ---------- —-- -__ __ 1 -- -- --- 7 } Did employee lose at least one full shift's work? Time employee began work: ❑ AM ❑ PM ❑ No ❑ Yes, 1s1 date absent(MMIDDIYYYY)1 1 l Has employee returned to work? ❑Regular work ❑ Restricted work❑ No,still off work❑ Yes,date returned(MMIDDIYYYY)I-I-- { Did employee die? ❑ No ❑ Yes,date(MM/DDIYYYY) 1 1 u -------------- --- --- ----......... ...._ Date employer notified of incident 1 near miss: (MMIDDIYYYY) 1 1 To om Other hreported: workers njuredlmade ill in this event?r]m Yes ❑ No r STANTEC Consulting Corporation Attachment 3 i