Work Incident/Accident Report Form

Date + Time Incident/Accident Occurred *

Date

Time

Date + Time Incident/Accident Was Reported *

Date

Time

Start Time of Scheduled Shift *

End Time of Scheduled Shift *

Name of Leader Incident/Accident Was Reported To

Leaders Name *

First

Last

Leaders Phone Number *

Leaders Position *

Worker/Statement explanation of Incident/Accident *

Rough explanation of accident/incident (e.g. where did it occur, what were you doing when it occurred, who was involved, description of pain/injury, wether conditions, foot wear on at the time, did the worker finish their shift, etc.)

Employee Details

Employee Name *

First

Last

Employee Date of Birth *

Phone Number *

Legal Gender *

Mailing Address *

Mailing Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Job Title *

Job Title

Is worker Salary or Hourly Based? *

Salary
Hourly

Incident/Accident Details

Did the incident/accident develop over time? *

IF YES: Date and Time of Incident/Accident

Date

Time

If the exact date of accident is not known, please use the date of the first missed work shift as a result of this injury or the date it was first reported to the Employer.

IF NO: Date and Time of scheduled shift started

Date

Time

IF NO: Date and Time of scheduled shift ended

Date

Time

IF UNKNOWN: Date and Time of Incident/Accident

Date

Time

Were the worker's actions at the time of the incident/accident... *

for the purpose of the business
part of the worker's regular work
located on property

Select all that apply

Location of Incident/Accident *

Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Injury Details

Part of the body *

E.g. Left Leg, Right Wrist, Head

Nature of injury

E.g. cut, concussion, burn

Return to Work Details

Has the employee missed work (hours or days) beyond the date of accident? *

Has the employee returned to work? *

Did the Employee complete their shift? *

Yes
No

Has the Employee returned to work? *

Yes
No
Will Be Returning

Employee Employment Type *

Part Time
Full Time

Digital Signature *

Please type your full name. This signature confirms that the above information is correct.

Name of Leader Incident/Accident Was Reported To

Employee Details

Incident/Accident Details

Injury Details

Return to Work Details

CONNECT

CONTACT US

CAREERS

SEARCH

Call 1-888-591-6240 to upgrade to a room with a stunning mountain view.

Call 1-888-591-6240 to discuss our pet friendly options and reserve your room.

Book a Flexible Family Room Option today!

Call 1-888-591-6240