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Employee Accident Incident Report
Support Worker to complete Sections 1 and 2 and forward without delay to the Case Manager in the event of any accident, incidsent or near miss.
Section 1 - Employee Details
Completion of this form does not constitute an employee claim for Workers' Compensation. These forms are available in the office.
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*
*
+
*
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Time Occurred
*
Section 2 - Classification
Please chose which best describes the event
*
Accident
-
Incident
Near miss
How long have you worked for the service?
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Describe what happened
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Location of accident/incident
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Describe any injuries (be specific)
*
What do you think caused the event
*
What immediate action did you take in response to the accident/incident/near miss?
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Did you report the event to the Case Manager
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Yes
No
Case Manager's Name:
Date reported
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Receive medical attention?
*
Yes
No
Doctor's Name:
Date examined
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Were there any witness/es? (If yes, please provide name & addresses)
*
Will you be making a Workers' Compensation or Volunteer Insurance Claim?
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Unsure
Yes
No
If you will be making a claim - please advise the office within 24 hours
Employee Signature
*
clear
Employee Position
*
Date
*
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Resolution:
Closed Out
Complete
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P:\FORMS AND POLICIES FOR COMMON CARE STANDARDS\Forms\WHS forms\Client Accident Incident Report revised 10032020 mh.docx