Administration Incident Reporting And Accident Investigation Form (Page 2 of 5) in pdf

Injury/Near Miss and Incident Reporting Investigation Form

Work Related Injury and/or Near Miss Form

Section I – To be completed by EMPLOYEE and submitted immediately following incident.

Section II & III & IV – To be completed by EMPLOYEE and PRINCIPAL

Section V – To be completed by PRINCIPAL

If the employee is too injured to complete any of the sections, the Workplace Safety and Health Co-chair will be involved

to help investigate the Incident.

Distribution

1. Before the end of the day fax copy of report to the Business office clerk for reporting to WCB (Payroll)

2. Keep original for continued follow-up to resolution and for final filing in staff file.

When preventive / corrective actions have been completed, signatures added and send report to: Park West Health and

Safety Officer

WCB Reporting Requirements – all staff excluding teachers

Workers Compensation Board (WCB)

Employers must report any work related injury/illness that involves time loss from work and/or a need for medical attention

to the WCB. Employers must report the incident within five (5) working days of the incident or within five (5) working days

of when they first learn of the incident. WCB charges late fees for reports that are delayed longer than 5 days post-injury.

Employers must ensure that the injured/ill worker is given a benefits package if the worker requires medical attention or

misses time from work as a result of the work related injury/illness.

This applies to Support Staff only as Teachers are not covered by WCB

SERIOUS INCIDENT REPORT REQUIREMENTS – WHERE APPLICABLE

Manitoba Family Services and Labour - Workplace Safety and Health Division

Serious injuries must be reported to Manitoba Family Services and Labour at 945-0581 or toll free (1-866-888-8186). The

Workplace Safety and Health Division considers an accident to be serious if it results in serious injury (worker is killed,

injury resulting from electrical contact, unconsciousness as the result of a concussion, a fracture of his or her skull, spine,

pelvis, arm, leg, hand or foot, amputation of an arm, leg, hand, foot, finger or toe, third degree burns, permanent or

temporary loss of sight, a cut or laceration that requires medical treatment at a hospital as defined in the health services

insurance act, or asphyxiation or poisoning. The Safety Division also considers the event a serious incident if the event

involves; the collapse or structural failure of a building, structure, crane, hoist, lift, temporary support system or

excavation, an explosion, fire, or flood, an uncontrolled spill or escape of a hazardous substance, or the failure of an

atmosphere-supplying respirator).

1. Reported to Provincial WS&H Division:  Yes

 No (does not meet requirement).

2. If Yes: Name of Workplace Safety & Health Officer contacted: ___________________________________________

Name of person who contacted WS&H Division: _________________________________ Date: ___________________

3. Reported to the Co-chairs of Workplace Safety & Health Committee:  Yes Date: ____________________________

When to contact Police:

Any and all incidents involving personal safety, building security, loss of property, vandalism, thefts, frauds, violence,

disturbances, threats and accidents; which occur on property, or directly impacts a worker providing service to a client in

the community must be reported to Police.

Employee Name: __________________________

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