APPENDIX 5
INCIDENT/ACCIDENT REPORT AND ASSESSMENT

Incident/Accident Report and Assesment in PDF format
Incident/Accident Report and Assesment in MS Word format

To be completed by field trip leader in the event of an incident involving serious injury
and/or damage to property, and filed with LOC Safety Officer or Section/Division Head or
designate)


Name of Person Involved (PRINT)
 
Date of Occurrence
 
Time
 
First Aid or Medical Attention Required: 
Yes: _____         No: _____
Damage to Equipment:
     Yes: _____         No: _____
Field Trip Leader's Name
 
Field Trip Leader's Signature
 
Report Date
 
Reported By
 
Reported To (police, other authority)
 
Copy Sent to GAC Safety Committee 
Date:
Date of Notification
 
Field Trip Participant's Signature
 
Workers Compensation Form Completed?
  Yes: _____          No: ______
   (If Yes, Please Attach Copy)
Date of Completion of Form
 
 
Location of Occurrence (Outcrop, Highway, City, etc.)
 
 
Other Personnel Involved in Incident/Accident
 
 
Field Trip Participant's Report of Incident/Accident. Describe Activity That Led to Incident/Accident Stating What Equipment (e.g., tools, etc.) Was Involved. Describe the Nature and Cause of the injury.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 

Are There Any Witnesses?  Yes: _____         No: ______
Names and Addresses of Witnesses
 
 
 
 
 
 
 
 
 
 

Statements of Witnesses First on Scene of Incident/Accident
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Statements of Other Witnesses
 
 
 
 
 
 
 
 
 
 
 

If more space is required use a separate sheet of paper.

Last modified: May 2, 2010
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