Minor Injury Reporting Form
Please fill out this form if you did NOT receive Medical attention. If medical attention is required please fill out WSIB form 6 and report to Health & Safety
Injured Person
First Name
Last Name
Date and Time of Injury
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Injury
Please give address the injury took place.
Description of Injury
Cause of Injury
Was First Aid Administered?
Please Select
Yes
No
If Yes Who Administered First Aid?
Full Name
Severity of Injury
Please Select
Minor
Moderate
Severe
Were there any witnesses?
Yes
No
Witness
First Name
Last Name
Evidence
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Additional Comments
Submit
Should be Empty: