Exposure Incident Reporting Form

Employer's Information

Employee Information

Location of Incident

Did the project have a Joint Health and Safety Committee (JHSC)?

Did the project have a Joint Health and Safety Committee Representative?

Yes No Unsure

Yes No Unsure

If your answer was yes to either of the previous two questions, please upload the JHSC or Representatives incident report to this form. If your answer was no, please upload an employer or first aid incident report if possible to this form.

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Describe what occurred

Was a workers compensation claim made related to this incident?

Was a formal incident report made to a government agency?

If yes, did a government official attend the job site?

Was an MSDS available about the substance(s) involved?

Was exposure monitoring or air sampling done after the incident?

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