Form 6A – Employee Report to Employer
OHS Email
*
WorksafeBC Claim # (if known)
Incident ID Number
*
This has been provided in your notification Email
Name
*
First
Last
Employee #
*
Your District Email Address
*
Incident Location
*
Admiral Seymour Elementary
Bayview Community Elementary
Britannia Community Elementary
Britannia Community Secondary
Captain James Cook Elementary
Carnarvon Community Elementary
Champlain Heights Annex
Champlain Heights Community Elementary
Charles Dickens Annex
Charles Dickens Elementary
Chief Maquinna Elementary
Collingwood Neighbourhood Elementary
Crosstown Elementary
David Livingstone Elementary
David Lloyd George Elementary
David Oppenheimer Elementary
David Thompson Secondary
Dr A R Lord Elementary
Dr Annie B Jamieson Elementary
Dr George M Weir Elementary
Dr H N MacCorkindale Elementary
Dr R E McKechnie Elementary
Ecole Jules Quesnel Elementary
Ecole Laura Secord Elementary
Edith Cavell Elementary
Elsie Roy Elementary
Emily Carr Elementary
Eric Hamber Secondary
False Creek Elementary
Florence Nightingale Elementary
G T Cunningham Elementary
Gathering Place Education Centre
General Brock Elementary
General Gordon Elementary
General Wolfe Elementary
Gladstone Secondary
Graham Bruce Elementary
Grandview Elementary
Hastings Community Elementary
Henry Hudson Elementary
J W Sexsmith Elementary
John Henderson Elementary
John Norquay Elementary
John Oliver Secondary
Kerrisdale Annex
Kerrisdale Elementary
Killarney Secondary
King George Secondary
Kitsilano Secondary
L'Ecole Bilingue Elementary
Lord Beaconsfield Elementary
Lord Byng Secondary
Lord Kitchener Elementary
Lord Nelson Elementary
Lord Roberts Annex
Lord Roberts Elementary
Lord Selkirk Annex
Lord Selkirk Elementary
Lord Strathcona Elementary
Lord Tennyson Elementary
Magee Secondary
Maple Grove Elementary
Mount Pleasant Elementary
Nootka Community Elementary
Norma Rose Point School
Pierre Elliott Trudeau Elementary
Point Grey Secondary
Prince of Wales Secondary
Queen Alexandra Elementary
Queen Elizabeth Annex
Queen Elizabeth Elementary
Queen Mary Elementary
Queen Victoria Annex
Quilchena Elementary
Renfrew Community Elementary
Shaughnessy Elementary
Simon Fraser Elementary
Sir Alexander Mackenzie Elementary
Sir Charles Kingsford-Smith Elementary
Sir Charles Tupper Secondary
Sir Guy Carleton Comm Elementary
Sir James Douglas Annex
Sir James Douglas Elementary
Sir John Franklin Elementary
Sir Matthew Begbie Elementary
Sir Richard McBride Annex
Sir Richard McBride Elementary
Sir Sandford Fleming Elementary
Sir Wilfred Grenfell Elementary
Sir Wilfrid Laurier Elementary
Sir William Osler Elementary
Sir William Van Horne Elementary
Sir Winston Churchill Secondary
South Hill Education Centre
Southlands Elementary
Tecumseh Annex
Tecumseh Elementary
Templeton Secondary
Thunderbird Elementary
Tillicum Community Annex
Trafalgar Elementary
Tyee Elementary
University Hill Elementary
University Hill Secondary
Vancouver Learn Network Elementary
Vancouver Learn Network Secondary
Vancouver Technical Secondary
Walter Moberly Elementary
Waverley Elementary
Windermere Community Secondary
Xpey' Elementary
Date of incident or exposure start date
*
Date Format: MM slash DD slash YYYY
Time of incident
*
:
HH
MM
AM
PM
Did you report this incident to your Administrator or Manager?
*
Yes
No
Name of Person you reported it to
*
First
Last
Date reported to Supervisor
*
Date Format: MM slash DD slash YYYY
Time reported
*
:
HH
MM
AM
PM
Did you receive First Aid?
*
Yes
No
Date of First Aid
*
Date Format: MM slash DD slash YYYY
Name of First Aid Attendant
*
First
Last
Did you see or will you be seeing a physician or other medical treatment provider?
*
Yes
No
Name of Physician or provider
*
First
Last
Phone number of physician or treatment provider
*
Are you aware of any recent pain or disability in the area of your reported injury?
*
Yes
No
If yes, explain
*
Were there any witness to the incident?
*
Yes
No
Witnesses
*
Click on the + button to add additional witnesses
Witness Name
Position/relation
Contact information
Administrator/Managers in charge at the time of the incident
First
Last
Describe the exact location of where the incident took place
*
Describe in detail the sequence of events leading up to the incident and describe the incident itself
*
Primary Injury
*
abdomen - upper
abdomen - lower
abdomen - mid
ankle- left
ankle- right
arm- left
arm- right
back - left
back - upper
back - right
back - lower
back - mid
buttocks
chest
ear- left
ear- right
elbow- left
elbow- right
eye- left
eye- right
face
finger- left
finger- right
foot- left
foot- right
groin- left
groin- right
hand- left
hand- right
head
hip- left
hip- right
knee- left
knee- right
leg- left
leg- right
mouth
neck- left
neck- right
no physical injury
nose
other
shoulder- left
shoulder- right
teeth
toe- left
toe- right
wrist- left
wrist- right
Nature of injury
*
abrasion
amputation
bruise
burn, scald
concussion
cut/laceration
dislocation
electrical shock
fracture
gradual onset
inflammation
open wound
psychological
puncture
respiratory disorder
sprain
strain
Did you sustain any other injuries as a result of this incident?
*
Yes
No
Secondary injury
*
abdomen - upper
abdomen - lower
abdomen - mid
ankle- left
ankle- right
arm- left
arm- right
back - left
back - upper
back - right
back - lower
back - mid
buttocks
chest
ear- left
ear- right
elbow- left
elbow- right
eye- left
eye- right
face
finger- left
finger- right
foot- left
foot- right
groin- left
groin- right
hand- left
hand- right
head
hip- left
hip- right
knee- left
knee- right
leg- left
leg- right
mouth
neck- left
neck- right
no physical injury
nose
other
shoulder- left
shoulder- right
teeth
toe- left
toe- right
wrist- left
wrist- right
Nature of injury
*
abrasion
amputation
bruise
burn, scald
concussion
cut/laceration
dislocation
electrical shock
fracture
gradual onset
inflammation
open wound
psychological
puncture
respiratory disorder
sprain
strain
Additional injury information
Contributing factors
*
Lifting
Pushing
Pulling
Carrying
Repetitive motion
Slip or trip
Fall
Twist
Struck
Crush
Sharp edge
Harmful substance
Animal bite
Assault
Motor vehicle accident
Unsure/other
Weight lifted, pulled, carried or pushed (in pounds)
*
Explain
*
Did you or will you miss any time from work beyond the date of injury or exposure?
*
Yes
No
Additional information
Date
Date Format: MM slash DD slash YYYY