Workplace Injury Report

Worker Name:

Occupation:

Injury Date:

Date & time reported:

am pm

Address:

Employer:

Location where injury occurred:

Statement of Injury: Describe in detail what happened to cause the injury. Use additional pages as necessary.

Injuries and Treatment: List all injuries and treatments

Circle area(s) of injury

Color:

Draw on the diagrams below to mark the injury location

Front View

Color:

Back View

Color:

Witnesses: List name(s) and employer(s)

Supervisor: Provide notification

Name:

Cell:

Notified?

Yes No To follow

Do you have a pre-existing injury/condition in this body area?

Yes No

If Yes, provide details:

Offer of Light Duty Check appropriate box

Please be advised that [ADD NAME OF EMPLOYER]

DOES DOESN'T

offer light duties to Employees who've sustained a workplace injury. If provided, your Employer will modify your duties as necessary to accommodate your medical restrictions/limitations during your recovery period.

Worker Acknowledgement Check appropriate box

I understand that I

HAVE BEEN HAVE NOT BEEN

offered modified duties by my Employer.

Worker Signature:

Sign above with your finger or stylus

Date:

First Aid Attendant Name:

Employer:

Privacy Notice: The personal and health information collected on this form is used solely for reporting and managing workplace injuries in accordance with applicable occupational health and safety laws. It will be sent to the MAG Group safety team and may be shared with your provincial workers' compensation board. Information is retained as required by law. You may request access to or correction of your information by contacting your supervisor. By submitting this form, you consent to the collection, use, and disclosure of your information as described above.

I have read and consent to the collection of my personal and health information as described above.