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<br />Form 140 – Page 1 of 2 <br />Workers Accident / Incident / Occupational Illness Report <br />This form must be completed in its entirety and FAXED to <br />EMPLOYEE WELLNESS within 24 hours <br />Please call 613-596-8250 for assistance – FAX: 613-596-8798 <br />A: Accident/Incident Type <br /> incident-No injury Minor Injury-No Treatment First Aid <br /> Health Care Lost Time Occupational Illness <br />B: Worker Information <br />Last Name: First Name: <br />EIN: Date of Birth: <br />Sex: Male Female Do you currently have more than one job? yes no <br />Home Address: City: Postal Code: <br />Home Phone: Work Phone: Cell Number: <br />Work Location (Name of School): Occupation: <br />Immediate Supervisor: Phone: <br />C: Reporting of Accident or Occupational Illness <br />Date of Incident: Time of Injury: am pm <br />OR <br />Did condition develop over time? yes no <br />Hours worked on day of injury: From ___ To ___ Regular working hours: From __To _______ <br />Date reported: Time: am pm Accident reported to: <br />If there was a delay in reporting accident, list reason(s): <br />Did you receive health care for this accident/incident? yes no <br />If yes, provide name, phone number, address and appointment date of attending health care professional or hospital. <br />Did the injury occur on the employer’s premises? yes no <br />If yes, Accident location: _______ ____ If no, Acccident location: _______ <br /> (i.e. Gym, Classroom, yard etc.) <br />Was the work you were doing for the purpose of your employer? yes no <br />If yes, was it part of your usual work? yes no <br />D: PLEASE INDICATE AREA OF INJURY (Left/Right) Please all that apply): <br />Head Eye(s) Face Ear(s) Teeth Neck <br /> Chest Upper Back Lower Back Pelvis AbdomenOther __________ <br />Shoulder <br />LRArmLRElbowLR <br />ForearmL R Wrist L R Hand L R <br />Finger(s)L R Hip L R Thigh L R <br />KneeL R Lower leg L R Ankle L R <br />Foot L R Toe(s) L RL Other ____________ <br />Accident Details <br />Describe fully what happened to cause this injury or illness. Describe what you were doing and include any <br />tools, equipment, materials, etc. Be specific of weights and size of objects. State any gas, chemicals or <br />extreme temperatures you may have been exposed to. If necessary attach additional information. <br />Describe the accident in detail: <br />2014 July <br /> <br />