EHS Injury Report and Investigation
This procedure outlines the reporting and investigation of workplace injuries, including recording incident details, gathering evidence, and tracking corrective actions to completion.
Big Country Raw
10/05/2026
EHS Injury Report and Investigation
The aim is to document workplace injuries, identify contributing factors and root causes, and establish corrective actions to prevent recurrence. It supports timely reporting, clear accountability, and continuous improvement in workplace health and safety.
Division Selection
Select the division
Worker Information
Enter worker's last name
Enter worker's first name
Enter job title/occupation at time of incident
Enter length of time in this position (in months)
Enter supervisor's name
Enter name of person reporting incident
Accident/Incident Details
Date/Time of Incident
Date/Time incident was reported to Supervisor
Accident/Illness Type
Was workers limitations for this injury provided to the supervisor?
Section #4
Was the accident/illness:
Type of Contact
Which Side
Describe what happened to cause the accident/ injury and, if applicable, describe the injury. Include workers activities at the time of accident/injury and any important details. Attach a diagram if appropriate.
Weight and size of objects involved
Equipment/Material involved
Was any individual who does not work for the company responsible for this injury? (If yes, provide details)
Was a copy of worker's limitations provided to HR
Witness Info
Name, address, contact info
Witness Statement (attach if available)
Add or drag pictures
Acknowledgement of Important Information: Once you have received notification of a worker Accident / Incident, immediately the Department Manager & HR Business Partner. Timely reporting of Injuries by Employees and Supervisors ensures the necessary follow-up occurs and ensures the applicable Workers Compensation Board is notified within 3 days of injury by the HR department to avoid $250 fine. Unnecessary fines will be charged to the applicable department.
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Treatment/Healthcare
Check all that apply
Date of First Aid Treatment (if applicable)
Date of Health Care treatment
Name and Address of treating Medical Practitioner
Are you aware of previous pain or disability in the area of the worker's present injury? If yes, please provide details.
When did employer learn worker received Health Care for this injury?
Lost Time/ No Lost Time
Date worker left work due to injury
Date Supervisor was notified that worker left work due to injury
Check following to ensure necessary steps are followed to prevent Lost Time Injury
Describe the modified suitable duties offered to the employee
Offer Accepted (both employee and supervisor or designate sign here)
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Offer Declined (both employee and supervisor or designate sign here)
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Return to Work
Choose one of the following: After day of accident / awareness of illness, this worker:
Date worker first lost time (not including shift that incident occured)
List Normal shift on day of incident
Distribution
Accident/Incident Investigation (Cause Analysis)
Substandard Actions
Substandard Conditions
Personal Factors
Job Factors
EH&S Management System Controls
Program/element needs: (Check all that apply)
Corrective Action Plan
Corrective Actions were in place and working? (add necessary corrective actions here)
Report Review
Name and Signature of Injured Worker
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Name and Signature of Investigator
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Name and Signature of JHSC Member/Safety Rep
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Name and Signature of Supervisor Completing Report
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Source: Big Country Raw (Community Member)