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H&S Plan Accident/Inc -int Investigation Report Page 1 of 2 Instructions: If an accident or incident occurs, complete all applicable information in this form, make a copy for your records, and immediately forward the original to the office Health and Safety Coordinator (HSC). If fields are not applicable, indicate with "NA". Use separate sheet(s) if necessary and attach sketches, photographs, or other information that may be helpful in understanding how the accident/incident occurred. HSC — Review and enter report into the BC Online Safety Observation and Incident Reporting System within 3 workdays of receipt. File original in appropriate office health and safety file. NOTE: This report is important — please take the time necessary to properly complete it. Incomplete reports will be forwarded to appropriate management for review and action. General Information Date of Accident/Incident Time of Accident/Incident: Date Accident/Incident Reported: To Whom: Exact Location of Accident/Incident (Street, City, State): BC Office: Name Project: Project Number: Employee Completing the Investigation (Print and Sign): Date: in urea!! EmDloveeiProDertv Dama e Information Employee Name: Employee No. Department: Phone Number: Job Title: Manager's Name and Phone Number: Nature of Injury/Illness (laceration, contusion, strain, etc.): Body Part Affected (arm, leg, head, hand, etc.): Describe Property Damage and Estimate Loss : Description of Accident/Incident Describe the accident sequentially, beginning with the initiating event, and followed by secondary and tertiary events. End with the nature and extent of injury/damage. Name any object or substance and tell how they were included. Examples: 1) Employee was pulling utility cart that was loaded with wastepaper from office area to hallway. Wheel of utility cart caught against door casing. Bags of heavy wastepaper that were in cart fell to end of cart. Cart tipped over onto foot of employee. Right foot was crushed between utility cart and door casing, resulting in severe contusion to right foot of employee. 2) Employee was driving rental car from office to project site. Car struck icy section of road. Employee lost control of vehicle, which skidded across road into concrete abutment on side of road. Accident resulted in damage to right fender, tire, headlight, and grill. Distribution. Original — Office Health and Safety Coordinator; Copy #1 - Originator HS-19 REV. 06/2006