SUPERVISOR’S ACCIDENT INVESTIGATION

REPORT

Supervisors are responsible for completion of this form (Sections A to E inclusive) and delivery to the Employee Well-
Being Office, Suite A, East Office Building no later than 24 hours after occurrence. ( Fax # 416 736 5439). Any
additional information should be attached to the report.
Please tick appropriate box(es)
Incident First Aid Health Care* Lost Time
*Definition of Health Care: Those services, which can only be provided by a health care professional.

SECTION A: EMPLOYEE INFORMATION (required by 14. How did accident happen?

WSIB)
_____________________________________________
1. Employee ID Number: ___________________________
_____________________________________________
2. Last Name: ____________________________________
_____________________________________________
3. First Name: ____________________________________
_____________________________________________
4. Home Phone Number.: __________________________
15. What was the worker doing?
5. Dept/Faculty employed: __________________________ _____________________________________________

6. Occupation: ____________________________________ _____________________________________________

7. Union/Affiliation: _______________________________ _____________________________________________

8. Dept Address: _________________________________ 16. List size, weight & type of materials involved:

9. Supervisor (PLEASE PRINT) _____________________________________________

Name: ________________________________________ _____________________________________________

Phone No.: ____________________________________ _____________________________________________

E-mail Address: ________________________________ 17. Describe injury/illness; part(s) of body involved.

Specify left or right side:
SECTION B: DETAILS OF OCCURRENCE _____________________________________________

_____________________________________________
10. Date of Occurrence: _____________________________
DD/MM/YYYY _____________________________________________
11. Time of Occurrence: ______________ A.M. P.M.
18. Where did it happen? (Building/Site, Room No., Type of site
12. Date reported to Supervisor: _______________________ e.g. office, classroom, etc.):
_____________________________________________
DD/MM/YYYY
13. Health Care provided by:__________________________ _____________________________________________

______________________________________________ ______________________________________________
19. Names and phone numbers of witnesses or persons having
______________________________________________ knowledge of the occurrence:
_____________________________________________
Distribution:

Supervisor Distributes: Copy to Employee Well-Being Office

Copy to Area Health and Safety Officer

Employee Well-Being Office

Distributes : Copy to Department of Health and Safety
Copy to Union (if any)

Official Form - Revised June 2006 – Revisions And Updates Maintained By The Employee Well-Being Office
 26. Rate of pay (daily): $ ____________________________
SECTION C: INVESTIGATION
27. Hours worked per week: _________________________
20. List ALL contributing factors based on your
investigation (include environmental conditions, 28. Does the worker’s schedule change from week to week?
horseplay, hazardous properties, personal protective Yes No
equipment, e.g. footwear, head protection, etc.):
29. Worker’s usual work days (Full time Half time )
______________________________________________
Sun Mon Tue Wed Thu
______________________________________________
Fri Sat
______________________________________________ 30. Accumulated sick credits _____________________ days.

______________________________________________ SECTION E: ACCIDENT INVESTIGATION TEAM

21. Specify any pre-existing conditions or circumstances 31. Signatures of all members of the Accident Investigation
which may have contributed to the occurrence. Team:

Supervisor: ____________________________________
_______________________________________
Worker JHSC Member: __________________________
_______________________________________
Employee (if possible): __________________________
_______________________________________
Date: ________________________________________
22. What actions were taken to prevent future occurrences? DD/MM/YYYY
_______________________________________
ADDITIONAL COMMENTS:
_____________________________________________
_______________________________________
_____________________________________________
_______________________________________
_____________________________________________
_______________________________________ _____________________________________________
SECTION D: EMPLOYEE LOST TIME INFORMATION
_____________________________________________
Complete only if employee is absent beyond day of accident.
(Employer is responsible for providing full pay the day of
_____________________________________________
injury.)
23. Date last worked: _______________________________

DD/MM/YYYY
24. Normal working hours on last day worked:

From: _____________ A.M. P.M.

To: _______________ A.M. P.M.

25. Date returned to work:

Date: _________________________________________
DD/MM/YYYY

Distribution:

Supervisor Distributes: Copy to Employee Well-Being Office

Copy to Area Health and Safety Officer

Employee Well-Being Office

Distributes: Copy to Department of Health and Safety
Copy to Union (if any)

Official Form - Revised May 18, 2007 – Revisions And Updates Maintained By The Employee Well-Being Office