Oil and Gas Occupational Safety and Health Regulations

	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 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 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