City of Saint John Online Incident Reporting Form

The City of Saint John collects your personal information under the authority of the Local Governance Act and the Right to Information and Protection of Privacy Act (RTIPPA). The information you provide will be used to assess and manage your claim and may be shared with departments, insurers, adjusters, or legal counsel as required. Your information will be protected and used only as permitted by law.

Please note this form is for both internal and external reporting. Please select "external submission" if the incident is not a result of a workplace incident.

IN THE EVENT OF A SERIOUS WORKPLACE ACCIDENT PLEASE CALL THE FOLLOWING:

1. WorkSafeNB: 1-800-999-9775

2. Immediate Manager

3. Safety Manager: Corey Curnew 506-721-1531

SUBMISSION DETAILS

Date and Time of Incident

Mins

AM/PM

Time

Form Completed By

Email for Submission Receipt

Is this an incident being reported on behalf of an employee or citizen?

Which organization are you employed with?

EMPLOYEE DETAILS

Employee Name

Driver

Drivers License Number

Is there a standard operating procedure for this task?

Have you been trained in this procedure?

Was Personal Protective Equipment provided?

Was it used?

Date and Time Work Began

Mins

AM/PM

Time work began

Date and Time work began formula

Date & Time work began

Ex) MM/DD/YEAR 12:00AM

What could have been done to avoid this incident?

Was a WorkSafeNB Form 7 – Employer Report of Injury or Illness Completed? (Required for Medical Aid beyond 1st Aid, Modified Duties or Lost Time)

Direct Supervisor Name

Direct Supervisor Email

firstname.lastname@saintjohn.ca

Direct Manager Name

Direct Manager Email

firstname.lastname@saintjohn.ca

Additional Manager Name (if applicable)

Employee Department Head Name

Employee Department

Department Record ID

CLAIMANT DETAILS (PERSON AFFECTED)

Claimant First Name

Claimant Last Name

Claimant Address1

Claimant Address2

Claimant City

Claimant State/Province

Claimant Country

Claimant Postal/Zip

Claimant Email

Claimant Best Contact Number

Claimant Fax

CLAIMANT INSURANCE DETAILS (IF AVAILABLE)

Claimant Insurer

Claimant Policy #

Claimant Insurer Phone

Claimant Insurer Email

Claimant Insurer Address

Claimant Insurer Adjuster Name

Claimant Claim #

WITNESS INFORMATION

Was there a witness to this incident?

YesNo

Witness 1 Name

Witness 1 Phone

Witness 2 Name

Witness 2 Phone

ADDITIONAL DETAILS / COMMENTS

Additional details and comments.

FILE UPLOADS

Please attach any photos or other pertinent files here. File Max: 1MB. Please resize larger images prior to upload.

File Upload 1

File Upload 2

File Upload 3

Thank you for your submission. Due to the high volume of inquiries, it may take up to 7-10 business days for a response. If you are not contacted within this timeframe, please contact us at Riskmgmt@saintjohn.ca.

I acknowledge that I have read and understand the City of Saint John’s Privacy Statement. I consent to the collection, use, and disclosure of my personal information for the purpose of assessing and managing my claim, in accordance with applicable legislation.

Abdomen	Back Lower	Back Upper
Bladder	Brain	Buttocks
Chest and/or ribs	Chin	Circulatory System
Collar Bone	Digestive System	Face and Facial bones
Finger(s)	Groin	Head
Heart	Hip	Kidney(s)
Larynx	Left Ankle	Left Arm
Left Ear	Left Elbow	Left Eye
Left Foot	Left Hand	Left Knee
Left Leg	Left Lung	Left Shoulder
Left Wrist	Liver	Mouth
Multiple Body Parts or Systems	Neck	Nervous System
Nose	Pancreas	Pelvis
Reproductive System	Respiratory System	Right Ankle
Right Arm	Right Ear	Right Elbow
Right Eye	Right Foot	Right Hand
Right Knee	Right Leg	Right Lung
Right Shoulder	Right Wrist	Sacrum or coccyx
Skull	Spinal cord /column /vertebra /disc	Spleen
Stomach	Thumb	Toe
Tooth	Trachea