• Select date

  • Add location

Type

  • Injury / Illness

  • Property Damage

  • Major Potential

  • Near Miss

  • Spill

  • Fire

  • Vehicle Collision

  • Other

  • Explain

  • Area of the accident / incident

  • Description Accident / Incident

  • Diagram of scene if needed

  • Witness(es): Please attach witness statement(s)

Description of Worker Injury / Illness

  • First Aid

  • Medical Aid

  • Modified Work

  • Lost Time

  • Fatal

  • Name of Worker

  • Age of Worker

  • Occupation

  • Nature or Injury, First Aid given

Description of Property Damage / Vehicle

  • Picture(s) of Damage

  • Explain Damage of Property / Vehicle / Site

  • Estimate Lost / Damage Cost

Signatures

  • Worker

  • Supervisor

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