VSB Form 6A – School Safety Association of BC

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*

Date of incident or exposure start date*

Time of incident*

: HH

MM

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*

Time reported*

: HH

MM

Did you receive First Aid?*

Yes
No

Date of First Aid*

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*

Nature of injury*

Did you sustain any other injuries as a result of this incident?*

Yes
No

Secondary injury*

Nature of injury*

Additional injury information

Contributing factors*

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

Form 6A – Employee Report to Employer