Title Page
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Date of Accident / Incident
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Completed by
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Document Number
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The responsibility for reporting any injury and requesting first aid or medical aid rests with the colleague. In cases where this is not possible, the Leader is responsible for ensuring that this requirement is met on behalf of the colleague. It is absolutely essential that this report is submitted to provide necessary proof in case of investigation, if a claim develops at a later date. THE LEADER MUST FORWARD THIS REPORT TO THE Director of Facility Operations, WITHIN 24 HOURS OF THE INJURY
Employee Details
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Name:
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Department:
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Position:
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Employment status
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Will the colleague be absent from work because of the injury?
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Normal Working Hours Day of Accident: start/finish
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Date and Hour Last Worked: (last shift worked)
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Next scheduled shift:
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Normal Work Days
- Sunday
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
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Normal Working Hours
Details of Accident
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Describe what happened to cause the accident/illness and what the colleague was doing at the time (e.g., lift a 50lb box, slipped on a wet floor, repetitive movements, etc.). Include what the injury is and any details of equipment, materials, environmental conditions (e.g., work area, temperature, noise, chemical, gas, fumes, another person) that may have contributed
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Date and Hour of Accident:
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Date and Hour Reported:
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Details of Accident
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Where exactly did the accident occur? Specify where (e.g., office, vehicle, sidewalk, parking lot)
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Equipment or Object that was involved in the incident
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Weight of equipment or Object that was involved in incident:
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At the time of the injury was the colleague doing work other than work for Kananaskis Nordic Spa?
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Was any individual who does not work for Kananaskis Nordic Spa partially or totally responsible for this accident/illness?
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Was the accident/illness: (Please make a selection)
- Sudden Specific Event/Occurrence
- Gradually Occurring Over Time
- Occupational Disease
- Fatality
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Type of accident/illness: (Please make a selection)
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Did the colleague receive health care for this injury?
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On Site First Aid
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If yes, when:
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First Aid Given:
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First Aid Provider
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Off Site Health Care
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If yes, when:
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What type of Health Care did the colleague receive
- Ambulance
- Hospital Emergency
- Admitted to Hospital
- Health Care Professional Office
- Walk-in Clinic
- Other
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When did Kananaskis Nordic Spa learn that the colleague received health care?
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Where was the colleague treated for this injury?
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Name, address and phone number of health care professional or facility who treated this colleague (if known)
Area of Injury (Body Part)
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Please Check All That Apply
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Area of Injury (Torso/Head)
- Head
- Face
- Eye(s)
- Ear(s)
- Teeth
- Neck
- Chest
- Upper Back
- Lower Back
- Abdomen
- Pelvis
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Area of Injury (Limbs) - Side of the body affected
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Area of Injury (Limbs) - Specify Limb
- Shoulder
- Arm
- Elbow
- Forearm
- Wrist
- Hand
- Finger(s)
- Hip
- Thigh
- Knee
- Lower Leg
- Ankle
- Foot
- Toes
Witness(es)
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Is there anyone else who may have witnessed or who may know about the injury and/or accident?
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Name(s) of Witness(es)
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Address(es) and phone number(s) if available
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If yes, please provide a copy of the email or text message
LEADER REQUIREMENTS
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If the injury was not reported immediately, provide a reason for the delay
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Are you aware of any prior similar or related problem, injury or condition?
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WCB Paperwork Submitted
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Do you have concerns about this Accident/Incident? If so, please share details
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Leader’s Signature:
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Date:
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JHSC Member Signature
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Date:
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Colleague’s Signature:
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Date:
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Follow up Date: (if required to check on colleagues health)
