Form
Form - Injury and Incident Report
Document FSSMS-FRM-48Stage 1Revision 4Version 0.3.3
Topic pages open on your jurisdiction, and requirements tables show its line. You can change this on any page.
One form for every injury, every exposure outside the routine crew exposure log, and every equipment failure. The member completes Part A before the end of the shift (or within 24 hours for a volunteer who has left the station); the officer completes Part B the same shift and sends the form to the health and safety officer and the district chief; the HSO completes Part C. The form feeds statutory reporting, workers’ compensation, event triage, the exposure record and the corrective action register (Incident Investigation and Learning Program elements 5.1 and 5.2; CSA Z1005:21, cl. 4.4).
This form is a factual record. It is used for statutory reporting, workers’ compensation and event triage. It is not a learning interview. Describe what happened in plain words. Do not describe anyone’s character or assign fault; the review process, if one follows, looks at conditions, not people.
| # | Field | Entry |
|---|---|---|
| A1 | Report type (tick all that apply): ☐ Injury ☐ Exposure ☐ Equipment failure ☐ Illness believed work-related ☐ Vehicle collision | |
| A2 | Member (role, station, service status: career / volunteer / paid-on-call / student) | |
| A3 | Date and time of the event | |
| A4 | Location (address or description; incident number if any) | |
| A5 | Activity at the time (fire attack, overhaul, search, driving, training evolution, station duty, medical call, other) | |
| A6 | What happened, in order (plain words) | |
| A7 | Injury: body part(s); nature (cut, burn, strain, fracture, cardiac symptoms, heat illness, other); mechanism (fall, struck by, caught between, overexertion, contact, other) | |
| A8 | Exposure: substance or agent (products of combustion, chemical with name if known, biological agent, noise, heat, cold, traumatic event); route (inhalation, skin, eye, ingestion, needle, other); duration; SCBA worn and for which phases; decontamination done (on scene / at station / none) | |
| A9 | Equipment failure: item, identifier or serial, failure mode, in use or in inspection, tagged out of service (yes / no) | |
| A10 | PPE worn (list) and condition | |
| A11 | Witnesses (roles) | |
| A12 | First aid or treatment received (on scene, clinic, hospital); treated by (role or facility) | |
| A13 | Fit to continue duty? (yes / no / unsure) | |
| A14 | Anything else the department should know | |
| A15 | Member’s initials and date (or “completed by officer on the member’s behalf because …”) |
| # | Field | Entry |
|---|---|---|
| B1 | Officer (role, station) | |
| B2 | Immediate actions taken (treatment, withdrawal, equipment tagged, hazard controlled) | |
| B3 | Does the event meet any item on the statutory reporting list? (yes / no; which item; the list your jurisdiction sets: J08 Incident Reporting and Investigation) | |
| B4 | Senior officer responsible for health and safety called? (date, time; who spoke to whom) | |
| B5 | Scene preserved? (yes / no / not applicable; what was moved and why) | |
| B6 | Reported to HSO and district chief (date, time) | |
| B7 | Crew exposure log completed for this fire? (yes / no / not applicable) | |
| B8 | Officer’s description of the conditions at the time (weather, light, staffing, fire conditions, time into the incident, fatigue, anything else) | |
| B9 | Hot debrief held? (yes / no; when) | |
| B10 | Officer’s initials and date |
| # | Field | Entry |
|---|---|---|
| C1 | Report reference | |
| C2 | Regulator notified? (required / not required; date, time; by whom; to whom; reference) | |
| C3 | Workers’ compensation board report filed? (required / not required; date; claim reference) | |
| C4 | JOHSC co-chairs notified (date) | |
| C5 | Exposure record updated (date) | |
| C6 | Triage date and tier set (Form - Event Triage Record) | |
| C7 | Register items opened (references) | |
| C8 | Acknowledged to member (date); feedback to member (date; summary) | |
| C9 | Equipment failure referred to Equipment Standards team (date) | |
| C10 | HSO initials and date |
| Field | Type | Required | Who completes |
|---|---|---|---|
| Report type | Multiple choice | Yes | Member |
| Member role, station, status | Lookup | Yes | Member |
| Date and time of event | Date-time | Yes | Member |
| Location; incident number | Free text; lookup | Yes | Member |
| Activity at the time | Single choice with “other” | Yes | Member |
| What happened | Free text | Yes | Member |
| Injury: body part, nature, mechanism | Multiple choice lists with “other” | Yes if injury | Member |
| Exposure: agent, route, duration, SCBA phases, decon | Choice lists; free text; yes/no | Yes if exposure | Member |
| Equipment failure: item, identifier, failure mode, in use/inspection, tagged | Lookup; free text; choice; yes/no | Yes if equipment failure | Member |
| PPE worn and condition | Multiple choice; free text | Yes | Member |
| Witnesses (roles) | Free text | No | Member |
| First aid or treatment | Choice; free text | Yes | Member |
| Fit to continue | Choice | Yes | Member |
| Anything else | Free text | No | Member |
| Member initials, date; or completed-by note | Text; date | Yes | Member or officer |
| Officer role, station | Lookup | Yes | Officer |
| Immediate actions | Free text | Yes | Officer |
| Statutory list item | Yes/no; choice from the jurisdiction’s statutory list | Yes | Officer |
| Senior officer called | Date-time; roles | Yes if statutory | Officer |
| Scene preserved | Choice; free text | Yes if statutory | Officer |
| Reported to HSO and district chief | Date-time | Yes | Officer |
| Crew exposure log done | Choice | Yes if fire | Officer |
| Conditions at the time | Free text | Yes | Officer |
| Hot debrief held | Yes/no; date-time | Yes | Officer |
| Officer initials, date | Text; date | Yes | Officer |
| Report reference | System identifier | Yes | Records system |
| Regulator notified | Choice; date-time; roles; reference | Yes | HSO |
| WCB report filed | Choice; date; reference | Yes | HSO |
| JOHSC notified | Date | Yes if statutory | HSO |
| Exposure record updated | Date | Yes if exposure | HSO |
| Triage date and tier | Date; choice | Yes | HSO |
| Register items | Reference list | No | HSO |
| Acknowledged; feedback | Dates; free text | Yes | HSO |
| Equipment referred | Date | Yes if equipment failure | HSO |
| HSO initials, date | Text; date | Yes | HSO |
Injury and equipment failure reports are kept per 05 Document Control and Records. Exposure reports are kept for the length of the member’s service plus the period your jurisdiction and its workers’ compensation board require (J09 Records Retention), because occupational disease claims arise decades later; the exposure record is the member’s evidence (CPSE, 2019, criterion 11A.10; NFPA 1550, 2024, ch. 15 and 16). The member may request a copy of their own exposure record at any time. Personal health information beyond what this form asks is not collected.
This chapter relies on the following legal requirements, which differ by province and territory. Check your jurisdiction’s section on each topic page before adopting it.
| Topic | What to check in your jurisdiction | Page |
|---|---|---|
| Incident Reporting and Investigation | Which deaths, serious injuries and no-injury events must be reported to the regulator and how fast; who else must be told (such as the committee); the duty to preserve the scene until released; the employer’s deadline to report to the compensation board; and whether that report also counts as notice to the regulator | J08 Incident Reporting and Investigation |
| Records Retention | Any retention period the law or the compensation board sets for injury and exposure records | J09 Records Retention |
Center for Public Safety Excellence [CPSE]. (2019). Fire and emergency service self-assessment manual (10th ed.). Commission on Fire Accreditation International. https://cpse.org/wp-content/uploads/2019/08/10th-Edition-FESSAM-Strikethrough-Underline-v.4.pdf
CSA Group. (2021). CSA Z1005:21 (R2026), Workplace incident investigation. https://www.csagroup.org/store/product/CSA%20Z1005:21/
National Fire Protection Association. (2024). NFPA 1550, Standard for emergency responder health and safety (consolidates NFPA 1500, 1521 and 1561). https://www.nfpa.org/codes-and-standards/nfpa-1550-standard-development/1550