WSBC Investigation Report Form Completed By Date of Event Time of Event 121234567891011 : 0030 AMPM Event Details What happened? Include the time leading up to, during, & immediately following the incident. Will the injured worker miss time from work beyond the day of injury Yes No Unknown at this time Treatment Provided First Aid Attendant Hospital, Clinic, Doctor, Dentist, RMT, Physio, Chiro Name of First Aid Attendant Name of Doctor Name and location of hospital or clinic Description of medical treatment received Was the injured worker treated in an emergency room Yes No Was the injured worker hospitalized overnight Yes No Were modified duties offered to the injured worker Yes No Injured worker has accepted the work restrictions offered Yes No Injury Type Allergic Reaction Amputation Blood Poisoning Bruise/Scrape/Swelling Burn (chemical, electrical, heat) Chipped/Lost Tooth Concussion Cut Dislocation Electrocution Eye Injury Fainting/Loss of Consciousness Fracture Frostbite/Frostnip Hearing Loss Heat Related Illness Hernia Mental Health Puncture/Sliver Respiratory Condition Skin Disorder/Dermatitis Sprain/Strain Other Other Injury Type Body Part Ab/Chest/Ribs Ankle Arm Back Buttocks Elbow Eye Foot/Toe(s) Groin Hand/Fingers Head/Face Hip/Pelvis Knee Leg Neck Shoulder Teeth Wrist Other Ankle Detail Left Right Arm Detail Left Right Buttocks Detail Left Right Elbow Detail Left Right Eye Detail Left Right Foot/Toe(s) Detail Left Right Groin Detail Left Right Hand/Fingers Detail Left Right Hip/Pelvis Detail Left Right Knee Detail Left Right Leg Detail Left Right Shoulder Detail Left Right Wrist Detail Left Right Other Body Part Other Body Part Detail Left Right Event Compressed/Crushed Contact with Electricity Exposure Chemical Exposure Hot/Cold Fire/Explosion Injured by Animal/Insect Noise Overexertion Pinched/Caught Repetitive Movement Slip/Trip/Fall Struck Other Other Event Please describe the event Object Animal/Human/Insect Dust/Particles Hand Tool Ladder/Scaffolding Mobile Equipment No Object Protruding Objects Slippery or Uneven Surface Stairs Vehicle Other Other Object Please describe the object Captcha If you are human, leave this field blank.
