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Aviation Occupational Health and Safety Regulations (SOR/2011-87)

Regulations are current to 2025-05-27 and last amended on 2025-03-26. Previous Versions

SCHEDULE 1(Subsection 10.6(1))

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Employment and Social Development CanadaEmploi et Développement social Canada

blank linePROTECTED B WHEN COMPLETED

blank lineDepartment File No.

blank lineRegional or District Office

HAZARDOUS OCCURRENCE INVESTIGATION REPORT
  • 1 Type of occurrence

    ☐ Explosionblank line☐ Loss of consciousnessblank line☐ Other Specify

    ☐ Disabling injuryblank line☐ Emergency procedure

  • 2 Employer's name and mailing address (street, city, province and postal code)

Business number
Telephone number
Site of hazardous occurrenceDate and time of hazardous occurrence
Weather (if applicable)
WitnessesSupervisor's name
  • 3 Description of what happened

Brief description of property damage and the estimated cost of repair
  • 4 Injured or ill employee's name (if applicable)

AgeOccupation
Years of experience in occupation
Description of injury or illnessGenderDirect cause of injury or illness
Was training in accident prevention given to the employee in relation to duties performed at the time of the hazardous occurrence?

☐ Yesblank line☐ Noblank lineSpecify

  • 5 Direct causes of hazardous occurrence

  • 6 Corrective measures that will be taken by the employer and their implementation date

Reasons for not taking corrective measures
Supplementary preventive measures
  • 7 Investigator’s contact information

Last nameFirst nameTelephone number
TitleEmail
SignatureDate
  • 8 Work place committee member's or health and safety representative's contact information

Last nameFirst nameTelephone number
TitleEmail
Work place committee's or health and safety representative's comments
SignatureDate
ESDC LAB1070 E
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