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CS109 1118

A – Employer Information

Business Name Contact Person WSCC Account # Supervisor’s Name

Mailing Address Community Territory/Province Postal Code

Phone Number Fax Number Email Address

B – Type of Occurrence (Refer to page 5 for deﬁnitions of dangerous occurrences and accidents causing serious bodily injury.)

Answer ALL of the following questions.

Are you reporting:

• an injury, illness, or exposure?

Yes

• a dangerous occurrence as dened in section 1 of the Occupational Health and Safety Regulations? Yes

• an accident causing serious bodily injury as dened in section 1 of the Occupational Health and Safety Regulations? Yes

• a dangerous occurrence as dened in section 16.01 of the Mine Health and Safety Regulations? Yes

• a reportable incident involving serious injury or death as dened in section 16.01 of the Mine Health and Safety Regulations? Yes

C – Persons Involved

(Fill in a separate report for each injured worker. If this report is for a dangerous occurrence, as deﬁned in section 1 of the Occupational

Health and Safety Regulations, also include the name of each employer, principal contractor, and owner at the worksite.)

First Name Last Name Job Title Injured?

Yes

First Name Last Name Job Title Injured?

Yes

First Name Last Name Job Title Injured?

Yes

D – Place, Date, and Time of Incident

City Territory/Province Worksite

Date of Incident (mm/dd/yy) Time of Incident (am/pm) Date and Time First Reported to Employer

E – Incident Details

Describe incident in as much detail as possible. Include where it took place, what the worker was doing, what equipment was being used, and whether the

incident involved gas, chemicals, or extreme temperatures (attach extra page if more room is needed). Also state which part(s) of the body was injured.

Employer’s

Report of Incident

Attention: If you are only reporting a dangerous

occurrence, only complete page 1 of this report.

NOTE: To report an accident causing serious bodily injury or a dangerous occurrence,

you must call the 24-hour Incident Reporting line at 1-800-661-0792 as soon as is

reasonably possible and complete and submit this form within three business days.

The WSCC may use this information for the administration of legislation under our

authority, including the Workers' Compensation Acts (WCA), the Safety Acts, and/or the

Mine Health and Safety Acts, and their associated Regulations, and to contact you in

relation to the requirements under the relevant legislation. It is your responsibility when

providing an email address to ensure reasonable safeguards are in place to protect the

condentiality and security of your personal information within your email account.

If you need assistance ﬁlling in this form, or more information, contact us.

NWT Toll Free: 1-800-661-0792

• Nunavut Toll Free: 1-877-404-4407

Employers must submit this fully completed

incident report within three business days.

See page 4 for penalties as listed in the WCA.

CS109 1118

F – Injured Worker Information

First Name Last Name

Mailing Address Community Territory/Province Postal Code

Residential Address (if different than above) Date of Birth (mm/dd/yy)

Gender

Male

Female

Telephone (include Area Code) Cell (include Area Code) Email Address

Social Insurance Number Job Title (no abbreviations)

1. Does the worker work in more than one territory/province for your organization?

Yes

If yes, list the territories/provinces:

2. Was the injury or incident caused by a person(s) not employed by the employer? Yes

No (If yes, attach an explanation and contact info.)

3. Are you disputing this claim? Yes

No (If yes, attach an explanation.)

4. Were the worker’s actions at the time of injury for the purpose of your business? Yes

No (If no, attach an explanation.)

If yes, is the activity part of the worker’s regular work? Yes

No (If no, attach an explanation.)

5. Was First Aid given at the worksite? Yes

(If yes, attach a copy of the First Aid report.)

First Aid Provider’s name:

6. Did the worker seek medical attention beyond the worksite? Yes

(If yes, where? When? )

G – Return to Work (Give full explanations and attach extra sheets if necessary.)

7. Did the worker stop working? Yes No

What is the worker’s current status?

Returned to pre-injury job with no changes.

Returned to pre-injury job with duties changed.

Returned to pre-injury job with hours changed.

Returned to pre-injury job with duties and hours changed.

Returned to work in a different job to accommodate injury.

Other accommodations, specify:

When? Time: AM PM

Has the worker

returned to

work?

Yes

When? Time: AM PM

Has the worker been offered

alternate/modied duties? Yes No

8. Did you complete a Return to Work plan for this worker?

Yes No (Attach plan or forward within ﬁve days.)

If you would like assistance completing a Return to Work plan, call 1-800-661-0792 and ask for the Return to Work Specialist.

(mm/dd/yy)

H – Employment Category

9. Is the worker a subcontractor?

Yes No

If yes, who is the contractor?

10. Is the worker an owner or operator? Yes No

11. Worker’s Type of Employment (Check all that apply.)

Permanent

Term (Over 1 year)

Full / Part-time Permanent

Apprentice

Relief

Other

Non-permanent

Term (Under 1 year)

Term Start Date:

Term End Date:

Summer Student

Casual

Apprentice

Seasonal

Start Date:

End Date:

12. Is the job subject to seasonal layoffs? Yes No 13. Is the job subject to lack of work layoffs? Yes No

14. Worker’s day of hire (mm/dd/yy)

(mm/dd/yy)

CS109 1118

I – Schedule Information

15. Number of days on

Number of days off

16. Regular hours per day 17. Regular hours per rotation

18. Indicate days on for one full rotation. Place the number of hours scheduled below for each day worked. i.e. 8am-5pm; 7am-3pm, etc.

Sun Mon Tues Wed Thurs Fri Sat

Week 1 - Hours per day

Week 2 - Hours per day

Week 3 - Hours per day

Week 4 - Hours per day

19. Date rotation started (mm/dd/yy) Date rotation ended (mm/dd/yy)

20. Are travel days included in the on/off work rotation?

Yes No 21. How many hours are paid for on travel days?

J – Wage Information (Complete all questions.)

22. What is the hourly rate of pay? / hour. What are the annual gross earnings?

What is the overtime rate? / hour.

If the worker is paid other than hourly or on salary, explain below in question 30. (i.e. worker is paid on commission, etc.)

23. Does the worker regularly work or get paid for overtime?

Yes No

If yes, how many hours per day are overtime?

Provide an estimate of regular overtime hours / day week month

24. What percent of vacation pay does the worker receive?

Is vacation pay paid on each cheque?

Yes No

Is vacation pay paid out once a year?

Yes No When:

Does the worker receive any other benets? (Northern Allowance, Bonus, etc.)

Yes No

If yes, explain in detail with amounts and averages:

Are these benets paid out to the worker with their regular pay cheque?

Yes No

25. Are you paying the worker for lost time?

Yes No If yes, provide the dates lost time will be paid

26. Will you continue to pay benets? (

i.e. Northern Allowance

) Yes No

Worker’s Full Name:

27. Wage and Schedule Contact Person: 28. Phone Number: 29. Email Address:

30. Provide any additional wage and schedule information here:

CS109 1118

Ce formulaire est disponible en français

ᑖᓐᓇ ᑕᑕᑎᕆᐊᓕᒃ ᐊᑐᐃᓐᓇᖅ ᐃᓄᒃᑎᑐᑦ

Una titiraq piinnarialik pilugu Inuinnaqtun

Provide any additional information here:

Completed by (print) Phone Number Date (mm/dd/yy)

It is your responsibility to provide a copy of the Employer’s Report of Incident form to your worker.

ATTENTION:

An employer who does not submit a fully completed incident report within three business days, as required by the Workers' Compensation Acts (WCA),

faces the following penalties:

• $250 for each of the ﬁrst two occurrences;

• $500 for each of the next two occurrences; and

• $1000 for each additional occurrence.

Submit completed form to the appropriate WSCC ofﬁce using the contact information below.

Head Ofce: Box 8888 • Yellowknife, NT X1A 2R3 • Telephone: (867) 920-3888 • Toll Free: 1-800-661-0792 • Fax: (867) 873-4596

Toll Free Fax: 1-866-277-3677 • Email: reportsnwt@wscc.nt.ca

Box 669 • Iqaluit, NU X0A 0H0 • Telephone: (867) 979-8500 • Toll Free: 1-877-404-4407 • Fax: (867) 979-8501

Toll Free Fax: 1-866-979-8501 • Email: reportsnu@wscc.nu.ca

wscc.nt.ca • wscc.nu.ca

Worker’s Full Name:

CS109 1118

NORTHWEST TERRITORIES AND NUNAVUT

SAFETY ACT

OCCUPATIONAL HEALTH AND SAFETY REGULATIONS

INTERPRETATION

1. In these regulations,

“accident causing serious bodily injury” means an accident at a work site that

(a) causes or could reasonably be expected to cause the death of an individual, or

(b) requires an individual to be admitted to a hospital as an in-patient for a period of 24 hours or more;

(accident causant des lésions corporelles graves)

“dangerous occurrence” means an occurrence that does not result in, but could have resulted in an accident

causing serious bodily injury, such as

(a) structural failure or collapse of

(i) a structure, scaffold, temporary falsework or concrete formwork, or

(ii) a tunnel, caisson, coffer dam, trench, excavated shaft or excavation,

(b) failure of a crane or hoist or the overturning of a crane or powered mobile equipment,

(d) bursting of a grinding wheel,

(e) uncontrolled spill or escape of a toxic, corrosive or explosive substance,

(f) premature or accidental detonation of explosives,

(g) failure of an elevated or suspended platform, or

(h) failure of an atmosphere-supplying respirator; (événement dangereux)

NORTHWEST TERRITORIES AND NUNAVUT

MINE HEALTH AND SAFETY REGULATIONS

PART XVI

16.01. In this part,

“dangerous occurrence” means

(a) an incident involving the hoist, sheaves, hoisting rope, conveyance or shaft timbering or structure,

(b) an inrush of water,

(d) an outbreak of re,

(e) a premature or unexpected explosion or ignition,

(f) the occurrence of ammable, noxious or toxic gas in mine workings or at an exploration site,

(g) unexpected and non-controlled extensive subsidence or caving of mine workings,

(h) an explosion or outbreak of re in any way related to the operation of an air compressor, air receiver,

compressed air line or steam boiler,

(i) a breakdown in the main ventilation system,

(j) loss of control or major damage to any mobile equipment,

(k) an uncontrolled fall of ground causing physical damage or the displacement of more than 50 t of material, and

(l) any unusual occurrence not listed in paragraphs (a) to (k); (événement dangereux)

“reportable incident” is an incident involving serious injury or death; (incident à signaler)

“serious injury” includes:

(a) a fracture of the skull, spine, pelvis, femur, humerus, bula, tibia, radius or ulna,

(b) an amputation of a major part of a hand or foot,

(d) any serious internal haemorrhage,

(e) any burn that is caused by electricity and requires medical attention,

(f) any third degree burn,

(g) any injury caused directly or indirectly by explosives,

(h) any asphyxiation or poisoning that causes a partial or total loss of physical control, and

(i) any other injury likely to endanger life or cause permanent impairment. (blessure grave)

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