COMPANY NAME *

THE FOLLOWING FORM REQUIRES COMPLETION WHERE THERE WAS LOSS OR DAMAGE TO PERSON, (INJURY OR FATALITY) PROPERTY/EQUIPMENT OR ENVIRONMENT AS SET OUT IN THE ALBERTA OCCUPATIONAL HEALTH AND SAFEY ACT, REGULATION AND CODE.

ALL INFORMATION HERE IN, SET FORTH, GATHERED BY, DELIVERED OR OBTAINED IN WRITING, ORALLY OR BY WAY OF INTERNET OR OTHER ELECTRONIC DEVICE DOES NOT TAKE PRECEDENNCE OVER THE ALBERTA OCCUPATIONAL HEALTH AND SAFETY LEGISLATION WITH WHICH ALL WORKERS SHOULD BE FAMILIAR.

INCIDENT/ACCIDENT REPORT

BEFORE YOU GET STARTED, DO YOU HAVE THE "WORKER" AND "EMPLOYER" HARD COPY FORMS TO BE SUBMITTED TO WCB? IF NOT YOU CAN PRINT THEM BY CLICKING BELOW. IF YOU DO NOT NEED THEM JUST IGNORE THE LINK BELOW.

GO TO WCB WEBSITE TO PRINT WORKER AND EMPLOYER FORMS

INCIDENT TITLE (EXAMPLE. "WORKER FALLS FROM LADDER"OR "CHEMICAL SPILL ON THE GROUND" ) *

TYPE OF INCIDENT *

INJURY

FATALITY

DAMAGE TO ENVIRONMENT

DAMAGE TO EQUIPMENT/CAPITOL

LOCATION ADDRESS AND CITY/TOWN *

WHO IS COMPLETING THIS FORM AND INVESTIGATION? *

TODAYS DATE * +

DATE OF INCIDENT OCCURANCE * +

TIME OF INCIDENT OCCURANCE *

AM OR PM? *

AM

PM

TIME OF FIRST ARRIVAL

AM OR PM?

AM

PM

NAME (S) OF FIRST ARRIVAL(S)

CITY *

GENERAL CONDITIONS

LIGHTING SUFFICIENT *

YES

NO

PROTECTED FROM PUBLIC *

YES

NO

WEATHER CONDITONS *

FAIR

POOR

VERY POOR (+OR- 30 DEGREES METRIC)

N/A - INDOORS

TERRAIN *

GOOD, NO ISSUES

POOR/UNEVEN GROUND ON ACCESS/EGRESS

OPEN HOLES NO BARRIERS

MUDDY/UNSTABLE/NO COMPACTIOn

SLIPPERY

TRIP HAZARDS/MARKERS/STEAKS/PINS/POTENTIAL STAB MATERIALS OR EQUIPMENT

NOISE CONDITIONS *

GOOD

MEDIUM (SOME BACKGROUND NOISE)

HI (REQUIRES EAR PROTECTION)