Accident / Injury Occurrence Report

Report every incident promptly, even minor ones. This takes about five minutes on your phone.

Complete every field below. Do not leave anything blank.

Report Date

Date * Required.

Personal Information

Full name * Enter your full name.

Address * Enter your street address.

City / town * Required.

Postal code * Required.

Phone (primary) * Required.

Phone (alternate)

Birth date * Required.

SIN * Required.

Your SIN is needed if this claim goes to WSIB. It is sent securely to the office and stored in a restricted list that only office staff can see.

Incident Details

Time accident happened * Required.

Time you reported it * Required.

Who did you report it to? * Required.

Area of injury (body part — e.g. left arm) * Required.

Did anyone on the crew witness it? *

Yes No

Select yes or no.

Witness name * Enter the witness's name.

Witness phone number * Enter the witness's phone number.

Describe the accident / occurrence in detail * Please describe what happened.

Medical Treatment

Are you seeking medical advice / treatment? *

Yes No

Select yes or no.

Where are you seeking treatment? Name, location, and doctor's name if known. * Please provide treatment details.

Acknowledgement

I understand that if the doctor recommends time off or modified duties, I need to submit a Functional Abilities Form (FAF) to the office. Copies are available for pick up in the office.

You need to check this box to submit.

Signature

Type your full name as your signature * Sign by typing your full name.

Date

Your supervisor countersigns this report once it's received at the office — no supervisor signature needed here.

* required — you'll get a chance to review everything first

Accident / Injury Occurrence Report

Report Date

Personal Information

Incident Details

Medical Treatment

Acknowledgement

Signature

Ready to send