Name Position Emergency Info Form Completed Informed Consent Forms Completed Full Legal Name e.g., Research Assistant X X Document Management Checklist Please ensure all documentation is handled as indicated below: Document Name Original to Accompany Principal Investigator in the Field Copy to be filed with Research Centre Copy to be filed with Employee Health Office Copy to be left with Designated Contact Person Completed Field Activities Plan √ √ √ Completed Emergency Contact Information Sheets √ √ √ Detailed Itinerary √ √ √ Signed Participant Consent Forms √ √ √ Final Equipment List √ √ √ Permits / Permissions √ √ Training Certificates √ √ √ Insurance information √ √ √ Vaccination Record √ √ √ Copy of Passport picture page, Visa(s) √ √ Blank General Hazard Assessment Form √ Blank Worksite Safety Inspection Checklist √ Blank OHS Occurrence Report Form √ Emergency Response Information (applicable to the field location) University Specific Contact Information Research Centre General 780-675-6651
APPENDIX 4 OCCUPATIONAL HEALTH AND SAFETY – OHS Occurrence Report Report No. Occurrence Date Time Reported to Supervisor Time Reported to AU OHS Time Occurrence Class: Other: Work Relation: Other: Occurrence Location: Other: Occurrence Area: Specific Location: Nature of Occurrence: Other: Source of Occurrence: Other: Nature of Injury: N/A Animal or Insect Bites or Venomous Asphyxia Benign Neoplasms/Tumors Bio Hazard Burns Carpal Tunnel Circulatory Concussion Contusions / Bruises Crushing Injuries Deafness, Hearing Loss, Impairment Dermatitis Epicondylitis Foreign Body Fractures H1N1 Influenza Head – Severe Hernia – Rupture Influenza Lacerations Mental Health / Psychological Neoplasms, Tumors, and Cancer Nervous System Non-Personal (Personal effects only) Nonspecific Injuries and Disorders Respiratory Poisonings and Toxic Effects Skin and Subcutaneous Tissue Strain or Sprain Systemic Tendonitis Trauma Other, please comment: Part of Body Injured: Abdomen/Pelvis Ankle Arm Back Brain Chest Ear Elbow Eyes Face Finger(s) Foot Hand Head and Face Hip and Thigh Internal Systems Knee Leg Multiple Systems Neck Personal effects only (no bodily injury) Shoulder and Upper Arm Teeth/Mouth Trunk Unknown Wrist Other, please comment: Right Left or Both Person(s) Involved in Occurrence Department Supervisor Name N/A Injured Person(s) Department Supervisor name Description of Occurrence:
Details: Details: Basic / Root Causes Personal Factors Job Factors Details: Details: Details: Details: List of Attachments to OHS Occurrence Report File: Witness Statement(s) WCB Employer Report WCB Employee Report WCB Physician’s Report Photographs / Sketches Progressive Injury Report Physical Demand Analysis Modified Work Agreement AU Online OHS Occurrence Report Other Immediate Corrective Actions Person Responsible Position Due Date Completion Date Long Term Corrective Actions to Prevent Recurrence Person Responsible Position Due Date Completion Date OHS Occurrence Investigation Team Name Signature Date (MM-DD-YYYY) Occurrence Report Review Department Supervisor Signature Date (MM-DD-YYYY) Department Manager Signature Date (MM-DD-YYYY) HR Advisor Signature Date (MM-DD-YYYY)
3. Risk Analysis: Frequency + Probability + Severity Frequency Probability Severity How often is the work process/task done or hazard encountered? How likely is an incident to occur? How severe could an incident be? What would be the most likely outcome? Frequently (i.e. daily) 4 Probable: Likely to occur immediately or soon 4 Catastrophic: Death, widespread occupational illness or injury, or loss of facilities 4 Often (i.e. weekly) 3 Reasonably Probable: Likely to occur eventually 3 Critical: Serious illness or injury resulting in lost time or restricted work, or damage>$25,000 3 Occasionally (i.e. monthly) 2 Remote: Could occur at some point 2 Marginal: Moderate illness or injury requiring medical aid, or 2 Rarely (i.e. annually) 1 Extremely Remote: Unlikely to occur 1 Negligible: Minor illness or injury requiring first aid, or damage<$1,000 1 Risk Ranking (total of checked values): 3-6:Minor 7-9:Moderate 10-12:Major