Incident Report Form - CMB Erectors

In an emergency Call 911 immediately

MOL must be notified in the event of a critical injury or death:

Call 1-877-202-0008 to report the incident to the Ministry of Labour’s Health and Safety Contact Centre
Details of the Incident
Date*
MM slash DD slash YYYY
Time*
Job Site*
Type of Incident*
Indicate Type of Incident if "Other"
Reported By*
First Last
Role in the Event*
Phone*
Email*
Witnesses
Click the + button to add as many rows as required.
First Name Last Name Phone Number
Describe the Incident*
Please use a separate sheet of paper to draw a diagram if required.
Describe any Illness or Injury*
What part of the body is affected and how?
Describe any Property Damage.*
What damage was caused and how?
Treatment
On site First Aid
Name of First Aid Provider
First Last
Emergency Room, Hospital or Clinic
Name of Doctor or Attendent
First Last
Notifications
WSIB Employer’s Report of Injury Form 7, Date:
MM slash DD slash YYYY
Health & Safety Representative, Date:
MM slash DD slash YYYY

First Name	Last Name	Phone Number

Details of the Incident