Injury Report Form
Personal Information
Name of Injured Person
*
First Name
Last Name
Sex
*
Male
Female
N/A
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Current Wage
*
Date of Hire
*
-
Month
-
Day
Year
Date
Full Years of Experience
*
Occupation at Time of Incident/Injury
*
Back
Next
Details of Injury/Disease
Date of Accident/Incident
*
-
Month
-
Day
Year
Date
Time of Incident
*
Hour Minutes
AM
PM
AM/PM Option
Where did the Accident/Incident Occur?
*
Date When Reported
*
-
Month
-
Day
Year
Date
Time Reported
*
Hour Minutes
AM
PM
AM/PM Option
Supervisor:
*
Was the injury?
*
Sudden
Occurring over time
Occupational Disease
Fatal
Types of Injury
*
Overexertion
Repetition
Fire
Fall
Harmful Substance
Violence/Harrassment
Slip/Trip
Other
Building/Area:
*
Specific Location:
*
Area(s) of Injury - Check All That Apply
*
Head
Face
Eyes
Ears
Mouth
Teeth
Neck
Chest
Upper Back
Lower Back
Abdomen
Pelvis
Left Shoulder
Right Shoulder
Left Arm
Right Arm
Left Elbow
Right Elbow
Left Forearm
Right Forearm
Left Wrist
Right Wrist
Left Hand
Right Hand
Left Finger(s)
Right Finger(s)
Left Hip
Right Hip
Left Thigh
Right Thigh
Left Knee
Right Knee
Left Lower Leg
Right Lower Leg
Left Ankle
Right Ankle
Left Foot
Right Foot
Left Toe(s)
Right Toe(s)
Describe what happened to cause the injury (activities, location, equipment used, etc)
*
Witnesses
Witness Name 1
First Name
Last Name
Position
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Witness Name 2
First Name
Last Name
Position
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Does this incident require reporting to the Ministry of Labour?
Yes
No
Does this incident require reporting to the WSIB?
Yes
No
Healthcare
Did the worker go to the hospital or clinic to be treated by medical professionals?
*
Yes
Do Not Know
No
Name of Healthcare Provider
*
Date of Healthcare Visit
*
-
Month
-
Day
Year
Date
Back
Next
Lost Time
After the day of the accident, this worker:
*
Returned to Regular Duties
Returned to Modified Duties
Has Lost Time/Earnings
No Contact w/Worker
Regular Work Schedule
(only fill out if lost time has occurred)
Regular Time IN and OUT on Sunday
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Regular Time IN and OUT on Monday
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Regular Time IN and OUT on Tuesday
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Regular Time IN and OUT on Wednesday
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Regular Time IN and OUT on Thursday
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Regular Time IN and OUT on Friday
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Regular Time IN and OUT on Saturday
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Regular # of Hours Per Week
Additional Information / Diagrams / Notes
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back
Next
Specific Information
Do you have any information that the worker could have returned to work earlier? Yes or No?
Who was the Injury Reported to? If injury/incident was not reported immediately explain why.
Do you have any reason to doubt that the injury/incident is work related. Explain why.
What can be done in the future to prevent this injury/incident from recurring?
Follow Up Information
Name of Person Reporting
*
First Name
Last Name
Signature
*
Submit
Should be Empty: