Contractor Incident Package

This package includes the following information. The initial package may not include the Cause and Effect Flowchart

or the Learning Experience Report:

: Incident Report Information – Slide 1 Company Name Date & Time of Incident Location of Incident Brief Description of Incident

Photos or Drawing of Incident Scene – Slide 2-? Supporting Documentation Associated with Incident

Copy of Pre-Task (STAC card, STAC insert) Copy of Job Execution Plan Copy of Safe Work Permit Copy of Witness Statements Copy of Contractor Training Badge Copy of NCCCO (Hoisting Incident only) Copy of Drivers License (Motor Vehicle Accident only) Copy of Material Safety Data Sheets – Name of Chemical and PPE section (Exposure only)

Cause and Effect Flowchart with Root Cause identified Corrective Actions with Assigned Target Dates and Assigned Responsibilities Learning Experience Report

Brief Description of Incident Key Learning’s Actions To Leverage Contact for More Information

Contractor Incident Package

• Company Name:

• Date & Time of Incident:

• Location of Incident:

• Brief Description of Incident:

Contractor Incident Package

Photos or Drawings of Incident Scene

Contractor Incident Package

STAC Card - Front

Contractor Incident Package

STAC card - Back

Contractor Incident Package

STAC Insert

Contractor Incident Package

Witness Statement

Contractor Incident Package

Training Badge

Contractor Incident Package

RCI Flowchart

Contractor Incident Package

Investigation Results

List Corrective Actions with Assigned Target

Dates and Assigned Responsibilities

Contractor Incident Package

What Happened? :

Key Learning's: In Summary:

Contact for More Info:

Learning Experience Report

Contractor Incident Package

Supporting Documentation Associated

with the Incident

• Copy of Pre-task (STAC, STAC insert)

• Copy of Job Execution Plan• Copy of Safe Work Permit• Copy of Witness Statements • Copy of Contractor Training Badge__________________________________• Copy of MSDS (exposure only)

• Copy of NCCCO (hoisting incident only)

• Copy of Drivers License (MVA only)