New Accident Investigation Report

This report is to be completed as soon as practical or within 24 hours after the incident. Complete this report if First Aid or Medical Aid has been provided or is required. If First Aid is required, also fill in the First Aid Log Book found in the first aid kit. If Medical Aid (any treatment other than first aid) has been provided or is required, complete and submit WSIB Form 7.

Identifying Details – Employer

Employer	Address
Supervisor	City
Telephone	Province
Fax	Postal Code

Identifying Details – Injured Employee

Name	Address
Age	City
Telephone	Province
Fax	Postal Code
Occupation	Experience at Work Involved
Nature of Injury (including if First Aid / Medical Treatment / Restricted or modified duty / or occupational illness; including body part affected & type of injury)

Witnesses

Witness (A)

Name	Address
Employer	City
Occupation	Province
Telephone	Postal Code

Witness (B)

Name	Address
Employer	City
Occupation	Province
Telephone	Postal Code

Witness (C)

Name	Address
Employer	City
Occupation	Province
Telephone	Postal Code

Accident Injury Care

a. First Aider	b. Doctor
Address	Address
City	City
Province	Province
Postal Code	Postal Code
Telephone	Telephone
c. Clinic	d. Hospital
Address	Address
City	City
Province	Province
Postal Code	Postal Code
Telephone	Telephone
e. Treatment and Care Provided

Reporting

Accident Date	Accident Time
Project	Location of Accident
Address	City, Province

Reported to Supervisor

Name	Telephone
Date	Time
Notes

Reported to Ministry of Labour (if Critical)

Name	Telephone
Date	Time
Notes

Reported to Head Office

Name	Telephone
Date	Time
Notes

Accident Report Part B: Accident Description

Explain what happened (what, where, when, who, how, weather, housekeeping, tools involved)
Sketch / Diagram (describe)
Immediate Cause
Underlying Cause
How can the accident be prevented from happening again?
Actions taken to prevent recurrence
Action / Due By	Report By

Signatures

Employee Signature	Date
Management Signature	Date