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2. Does the accident/incident involve an employee, or a member of the public?*

   1. Employee
   2. Public

   Check all that apply.

3. Date/Time Report*
   Date/Time Report

   Date/Time Report
4. Date/Time of Injury*
   Date/Time of Injury

   Date/Time of Injury
6. Name of Supervisor Completing Report*
7. Job Title*
9. Location of Accident/Incident *
11. Was anyone injured in the accident/incident?*

    1. Yes
    2. No
12. Who was injured?

    1. Employee
    2. Patron
14. Employee/Patron Description of Accident/Incident
16. Describe what the involved employee/patron was doing at the time of the accident, what happened, who was involved, nature of the injury, if any.
18. Description of Injury
20. Severity of Injury

    1. No Treatment Needed
    2. First Aid Only
    3. Doctor's Care
    4. Restricted Work Activity
    5. Incident
    6. Lost Time
    7. Near Miss
21. Date of Medical Treatment
    Date of Medical Treatment
23. Name of Doctor or Hospital:
25. Address of Doctor or Hospital
26. Phone Number of Doctor/Hospital
28. Hours lost on day of accident:

    Number

29. Did employee return to work?

    1. Yes
    2. No
30. Date Returned
    Date Returned
32. Brief explanation of severity of injury:
34. Witness Name
35. Statement Taken:

    1. Yes
    2. No
37. Witness Name
38. Statement Taken:

    1. Yes
    2. No
40. Photos Taken

    1. Yes
    2. No
41. Date/Time Photos Taken
    Date/Time Photos Taken

    Date/Time Photos Taken
42. By Whom?
44. Personal Protection Equipment (PPE) Used?

    1. Yes
    2. No
45. Type of PPE Used
47. Other equipment involved, if applicable, type of equipment
49. List any restricted work activities:
51. HAD INJURED PERSON BEEN PROPERLY INSTRUCTED IN SAFE AND EFFICIENT METHODS?

    1. Yes
    2. No
53. DID INJURED PERSON VIOLATE ANY INSTRUCTIONS?

    1. Yes
    2. No
55. WAS NECESSARY PROTECTIVE EQUIPMENT WORN? (IF APPLICABLE)

    1. Yes
    2. No
57. DID POOR HOUSKEEPING CONTRIBUTE TO INJURY?

    1. Yes
    2. No
59. DID HORSEPLAY CAUSE THE INJURY?

    1. Yes
    2. No
61. WAS INJURY CAUSED BY SOMETHING THAT NEEDED REPAIRS?

    1. Yes
    2. No
63. SHOULD A GUARD BE PROVIDED?

    1. Yes
    2. No
65. DID ANY BODILY DEFECT CONTRIBUTE TO INJURY?

    1. Yes
    2. No
67. WAS INJURY CAUSED BY AN UNSAFE ACT?

    1. Yes
    2. No
69. DID INJURED REPORT THE INJURY TO YOU, THE SUPERVISOR, IMMEDIATELY

    1. Yes
    2. No
71. Description of unsafe acts.
73. Did the injured employee or another person do something incorrectly?
75. What unguarded or unsafe condition of machinery, equipment, building or premises was involved (if any)?
77. ACTIONS TAKEN - After the injury, what did the employer do to correct the conditions that caused the injury?
79. What steps have been taken to prevent reoccurrence of this incident?*
81. What else, if anything should the employer do to prevent other accidents/incidents/injuries like this?
83. AS SUPERVISOR, DO YOU FEEL THAT THIS INJURY SHOULD BE COVERED UNDER WORKERS’ COMPENSATION?*

    1. Yes
    2. No
85. Reasons why or why not:
87. Additional Comments
89. All questions about Safety Policies/procedures should be directed towards your Supervisor or the Safety Coordinator Safety Person
Leave This Blank:


91. 1. Receive an email copy of this form.
92. Email address

    This field is not part of the form submission.

93. Submit

* indicates a required field