City of Saint John Online Incident Reporting Form

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

Date and Time of Incident

Mins

AM/PM

Time

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

Incident Time

A/P

AM/PM

Were police contacted?

Police Report #

Incident State/Province

Incident Country

What is the cause of this incident?

Please specify the other cause

Was there a Transit or City department involved in this incident?

YesNo (or not sure)

Was there a City vehicle, Transit vehicle or piece of equipment involved in this incident?

YesNo (or not sure)

Were there any injuries?

YesNo

Please provide Injury description

Was there Initial Medical Treatment?

YesNo

Initial Treatment (pick one)

(*Form 6 and 7 required)

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