Incident, Near Miss and Accident FormFill out the form below and we’ll be right with you!

If you don't wish to fill out the online form, please download the form here and send to your Canstaff contact as soon as possible.

Staff Name

First Name
Surname
Phone


I am reporting:

Incident Near Miss Accident
I saw something that could cause
an at-work injury.
Something happened and I was
nearly injured at work.
Something happened and I was
injured at work.


When did it occur?

Monday Tuesday Wednesday Thursday Friday Saturday Sunday
 
Date:
Time:
Time started at work:

Where were you?



Who saw it happen?



Please describe what happened or what could have happened



Your Signature Please type your full name
Date Reported


 

What type of accident was it?

Slip, Trip, Fall Chemical Hit Other

What part of your body was inured?

Head Neck Chest Abdomen
Hips/Groin Back Arm (L) Arm (R)
Leg (L) Leg (R) Hand (L) Hand (R)
Foot (L) Foot R) Ear Eye

What was the nature of your injury?

Cut Bruise Burn Sprain
Break Concussion Amputate Other

Treatment of Injury

None Doctor - Hospilization First Aid only Hospital
- If Doctor or hospitalization is required please download and take this form with you.

Did you stop work?

Yes - For how long? No
 

Do you have any additional comments or requests related to this accident?



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