Oil and Gas Occupational Safety and Health Regulations
Version of the schedule from 2014-05-29 to 2024-06-19:
SCHEDULE I(Subsection 16.4(3))Hazardous Occurrence Investigation Report
SCHEDULE I(Subsection 16.4(3))Hazardous Occurrence Investigation Report
Employment and Social Development Canada | 1. Type of occurrence | 2. Department file no. | ||||
□ Explosion | □ Loss of consciousness | |||||
HAZARDOUS OCCURRENCE INVESTIGATION REPORT | □ Disabling injury | □ Emergency procedure | Regional or district office | |||
□ Other | Specify | Employer ID no. | ||||
3. Employer’s name and mailing address | Postal code | |||||
Telephone number | ||||||
Site of hazardous occurrence | Date and time of hazardous occurrence | |||||
Weather | ||||||
Supervisor’s name | ||||||
Witnesses | Operator | |||||
Identification of drilling rig, drilling unit, production facility or support craft | ||||||
4. Description of hazardous occurrence | ||||||
Brief description and estimated cost of property damage | Operation in progress | |||||
5. Injured employee’s name (if applicable) | Age | Sex | ||||
Occupation | Years 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 ![]() | ||||||
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 investigating | Signature | Date | ||||
Title | Telephone number | |||||
9. Work place committee’s or health and safety representative’s comments | ||||||
Work place committee member’s or health and safety representative’s name | Signature | Date | ||||
Title | Telephone 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
- Date modified: