Title Page
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Prepared by
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Conducted on
Particulars of Accident
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Accident Date
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Accident Time
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Location
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Date Reported
The Injured Person
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Team Member First & Last Name
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Home Address
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Date of Birth
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Contact Phone Number
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Length of Employment
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Injury Type
- Bruising
- Dislocation
- Strain/Sprain
- Scratch/Abrasion
- Internal
- Fracture
- Amputation
- Foreign Body
- Laceration/Cut
- Burn/Scald
- Chemical Reaction
- Other
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Specify injured part of body
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Additional Comments
Damaged Property
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Property or material damaged:
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Attach media (if applicable)
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Nature of damage:
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Attach media (if applicable)
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Object/substance causing damage:
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Attach media (if applicable)
The Accident
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Describe what happened
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Drawing of the accident scene (i.e. for vehicle collisions)
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What caused the accident?
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How serious could it have been?
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How often is this likely to happen again?
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What action has or will be taken to stop another accident like this happening?
Action
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Description
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Completed?
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By whom
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When
Treatment and Investigation of Accident
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Type of treatment given
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Name of person giving first aid
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Doctor/Hospital
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Accident investigated by
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Signature
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Date
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WorkSafeBC advised?
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Select date
