Injury Report Form
Injured Person:
*
Name of person reporting: (if different)
Incident Type
Type:
*
Please Select
Injury
Exposure
Illness
Other
Date of Incident:
*
-
Month
-
Day
Year
Date
Supervisor:
Building/Area:
Specific Location:
Does this incident require reporting to the Ministry of Labour?
Yes
No
Does this incident require reporting to the WSIB?
Yes
No
Incident Information
Injured during normal work?
YES
NO
Was first aid given?
YES
NO
By whom?
Please list supplies used while administering First Aid
Were they transported for medical aid?
YES
NO
Where?
Name of Doctor:
Property/Equipment/Environmental Damage/Impact
Description of Damage:
Estimated Cost:
Critical Damage?
YES
NO
Analysis
Description of Incident:
*
Recommended corrective action(s):
Immediate:
Long Term:
Submit
Should be Empty: