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Oil and Gas Occupational Safety and Health Regulations (SOR/87-612)

Regulations are current to 2024-05-14 and last amended on 2023-12-15. Previous Versions

SCHEDULE I(Subsection 16.4(3))Hazardous Occurrence Investigation Report

Employment and Social Development Canada1. Type of occurrence2. Department file no.
□ Explosion□ Loss of consciousness
HAZARDOUS OCCURRENCE INVESTIGATION REPORT□ Disabling injury□ Emergency procedureRegional or district office
□ Other


Employer ID no.
3. Employer’s name and mailing addressPostal code
Telephone number
Site of hazardous occurrenceDate and time of hazardous occurrence
Supervisor’s name
Identification of drilling rig, drilling unit, production facility or support craft
4. Description of hazardous occurrence
Brief description and estimated cost of property damageOperation in progress
5. Injured employee’s name (if applicable)AgeSex
OccupationYears of experience in occupation
Description of injury
Was training in accident prevention previously given to injured employee in relation to duties performed at the time of the hazardous occurrence?
□ Yes □ No blank line Specify
6. Direct causes of hazardous occurrences
7. Corrective measures and the date on which employer will implement them
Reasons for not taking corrective measures
Supplementary preventive measures
8. Name of person investigatingSignatureDate
TitleTelephone number
9. Work place committee’s or health and safety representative’s comments
Work place committee member’s or health and safety representative’s nameSignatureDate
TitleTelephone number

Lab 369 (O&G) (rev. 2013–06–001)

COPIES 1 & 2 to Health and Safety Officer, COPY 3 to the Work Place Committee or Health and Safety Representative, COPY 4 to the Employer

  • SOR/94-165, s. 66
  • SOR/2014-141, s. 16

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