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)