The Workplace Injury Report Form is a crucial document required by Canadian federal and provincial legislation for reporting and documenting workplace accidents, injuries, or illnesses. This form must be completed whenever an employee experiences a work-related injury or illness, no matter how minor, to comply with Workers' Compensation Board requirements and Occupational Health and Safety regulations. The document serves multiple purposes: it initiates workers' compensation claims, provides a basis for workplace safety investigations, helps identify patterns in workplace incidents, and ensures proper medical attention is documented. The form must be filled out as soon as possible after an incident occurs, typically within 24-72 hours, depending on provincial requirements. This documentation is essential for protecting both employee rights and employer interests, while also contributing to overall workplace safety improvement initiatives.
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1. Employee Information: Basic details about the injured worker including name, employee ID, contact information, department, and job title
2. Incident Details: Date, time, and location of the incident, including specific workplace area or address
3. Nature of Injury: Description of the injury or illness, body parts affected, and type of injury (cut, burn, strain, etc.)
4. Incident Description: Detailed account of how the incident occurred, including tasks being performed and immediate circumstances
5. Immediate Actions Taken: First aid or medical treatment provided immediately after the incident
6. Witness Information: Names and contact information of any witnesses to the incident
7. Supervisor Review: Supervisor's assessment of the incident, including immediate corrective actions taken
8. Medical Treatment: Details of professional medical treatment sought, including healthcare provider information
9. Declaration: Signatures of employee, supervisor, and health and safety representative confirming accuracy of report
1. Equipment/Machinery Involved: Details of any equipment, tools, or machinery involved in the incident - include when incident involves equipment
2. Environmental Conditions: Description of environmental factors (weather, lighting, noise) that may have contributed - include for incidents where environmental factors are relevant
3. PPE Information: Details about Personal Protective Equipment being used at time of incident - include when PPE was required for the task
4. Chemical Exposure: Specific information about chemical exposure including WHMIS details - include for incidents involving hazardous materials
5. Return to Work Plan: Modified work arrangements and restrictions - include when time loss from work is expected
6. Previous Related Incidents: Information about similar previous incidents or recurring conditions - include when there is relevant incident history
1. Appendix A - Body Diagram: Diagram for marking location and type of injuries on human body outline
2. Appendix B - Incident Scene Photos: Photographs or diagrams of the incident scene, equipment, or conditions
3. Appendix C - Medical Documentation: Copies of relevant medical reports or certificates
4. Schedule 1 - Witness Statements: Detailed written statements from witnesses
5. Schedule 2 - Investigation Findings: Detailed investigation report including root cause analysis and recommendations
6. Schedule 3 - Follow-up Actions: Documentation of corrective actions implemented after the incident
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