Regulations Made Under Part II of the Canada Labour Code Respecting Occupational Safety and Health of Employees Employed on or in Connection with Exploration or Drilling for, or the Production, Conservation, Processing or Transportation of, Oil or Gas in Canada Lands, as Defined in the Canada Oil and Gas Act (SOR/87-612)

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Regulations are current to 2025-06-25 and last amended on 2025-03-26. Previous Versions

SCHEDULE I(Subsection 16.4(3))

Employment and Social Development Canada

Emploi et Développement social Canada

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1 Type of occurrence ☐ Explosion☐ Loss of consciousness☐ Other Specify ☐ Disabling injury☐ Emergency procedure
2 Employer's name and mailing address (street, city, province and postal code)		Business number
		Telephone number
Site of hazardous occurrence	Date and time of hazardous occurrence
	Weather (if applicable)
Witnesses	Supervisor'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)	Age	Occupation
		Years of experience in occupation
Description of injury or illness	Gender	Direct 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? ☐ Yes☐ NoSpecify
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 name	First name	Telephone number
Title	Email
Signature		Date
8 Work place committee member's or health and safety representative's contact information
Last name	First name	Telephone number
Title	Email
Work place committee's or health and safety representative's comments
Signature		Date

ESDC LAB1070 E