Fillable INJURY ANALYSIS REPORT (Workplace Safety & Prevention Services)

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INJURY ANALYSIS REPORT (Workplace Safety & Prevention Services)

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HealthandSafetyOntario.ca
A. Company Information
Firm Name
Firm Number Rate Number
Address
City/Town Postal Code
Reporting Period From To
Day Month Year Day Month Year
Prepared by Date
Day Month Year
INJURY ANALYSIS REPORT
Print Form
2
© 2012, Safe Workplace Promotion Services Ontario,
publicly known as Workplace Safety & Prevention Services.
1 877 494 WSPS (9777) | 905 614 1400 | www.wsps.ca
Injury Analysis Report
B. Nature of Injury or Disease
Department/
Occupation
Amputations
Bruises, contusions
Burns (chemical)
Burns or scalds (heat)
Cuts, lacerations
Fractures
Inflammation/irritation of
joints, tendons or muscles
Multiple injuries
Occupational illnesses
or disorders
Scratches/abrasions
Sprains, strains, tears
Surface wounds
(foreign bodies)
Total
As a %
%
%
%
%
%
%
%
%
%
%
%
%
Total
As a %
%
3
© 2012, Safe Workplace Promotion Services Ontario,
publicly known as Workplace Safety & Prevention Services.
1 877 494 WSPS (9777) | 905 614 1400 | www.wsps.ca
Injury Analysis Report
C. Part of Body
Department/
Occupation
Ankle(s)
Arm(s) (above wrist,
not elbows)
Back (including back
muscles, spine, spinal cord)
Elbow(s)
Eye(s)
Finger(s)
Foot/feet
Hand(s)
Head (not including eyes)
Internal injuries
Knee(s)
Leg(s) (not knee(s))
Multiple body parts
Shoulder(s)
Wrist(s)
Total
As a %
%
%
%
%
%
%
%
%
%
%
%
%
Total
As a %
%
4
© 2012, Safe Workplace Promotion Services Ontario,
publicly known as Workplace Safety & Prevention Services.
1 877 494 WSPS (9777) | 905 614 1400 | www.wsps.ca
Injury Analysis Report
D. Source of Injury or Disease
Department/
Occupation
Bodily motion/position of
worker (e.g., walking, climbing)
Boxes, crates, cartons
Chemicals
Furniture
Hand tools
(non-powered)
Hand tools (powered)
Ladders
Machines (e.g., presses,
extruders, mills, saws)
Non-powered vehicles
(e.g., hand trucks, dollies)
Powered vehicles
(e.g., forklifts, stackers)
Working surfaces (e.g., floors,
roofs, ramps, stairs, street)
Computers and Peripherals
Total
As a %
%
%
%
%
%
%
%
%
%
%
%
%
Total
As a %
%
5
© 2012, Safe Workplace Promotion Services Ontario,
publicly known as Workplace Safety & Prevention Services.
1 877 494 WSPS (9777) | 905 614 1400 | www.wsps.ca
Injury Analysis Report
E. Event of Exposure
Department/
Occupation
Bodily reaction
Caught in or compressed
by equipment or objects
Contact with temperature
extremes
Exposure to caustic, noxious
or allergenic substances
Fall on same level
Fall to lower level
Overexertion (in lifting pulling,
pushing, carrying, etc.)
Repetitive motion
Rubbed or abraded by
foreign matter in eye
Struck against object
Struck by object
Total
As a %
%
%
%
%
%
%
%
%
%
%
%
%
Total
As a %
%
6
© 2012, Safe Workplace Promotion Services Ontario,
publicly known as Workplace Safety & Prevention Services.
1 877 494 WSPS (9777) | 905 614 1400 | www.wsps.ca
Injury Analysis Report
F. Summary of Key Findings
G. Recommended Actions
7
© 2012, Safe Workplace Promotion Services Ontario,
publicly known as Workplace Safety & Prevention Services.
1 877 494 WSPS (9777) | 905 614 1400 | www.wsps.ca
Injury Analysis Report
H. The Cases
All Cases Cases As a % of total
From form 7 reports
From first aid reports
Total
Lost Time Cases Cases As a % of total
Total lost time cases
Total days lost
Days lost
Average days lost per case
Days lost per case
Health Care Cases Cases As a % of total
Total health care cases
I. Day and Time of Injury or Disease
Day of Injury or Disease Cases As a % of total
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Total
Time of Injury or Disease
12:00 - 12:59 1:00-1:59 2:00-2:59 3:00-3:59 4:00-4:59 5:00-5:59 6:00-6:59 7:00-7:59 8:00-8:59 9:00-9:59 10:00-10:59 11:00-11:59
Total
a.m.
p.m.
8
© 2012, Safe Workplace Promotion Services Ontario,
publicly known as Workplace Safety & Prevention Services.
1 877 494 WSPS (9777) | 905 614 1400 | www.wsps.ca
Injury Analysis Report
J. The Injured Workers
Length of Time on the Job Cases As a % of total
1 - 7 days
8 - 30 days
31 days - 6 months
More than 6 months, but
not more than 1 year
More than 1 year, but
not more than 3 years
More than 3 years, but
nor more than 5 years
More than 5 years
Total
Age Cases As a % of total
15 - 19 years
20 - 23 years
24 - 30 years
31 - 40 years
41 - 50 years
Over 50 years
Total
Gender Cases As a % of total
Female
Male
Total
© Workplace Safety & Prevention Services 2012. Workplace Safety & Prevention Services (WSPS) grants permission to
approved end users to reproduce this document in whole or in part, provided its intended use is for non-commercial,
educational purposes and that full acknowledgement is given to the WSPS. Approved end users are firms registered with
the Workplace Safety and Insurance Board. WSPS reserves the right to extend this permission to other stakeholders and
interested parties by express written permission upon application. WSPS extends no warranty to materials amended or altered
by the end user. Under no circumstances is this document, or any portion thereof, to be duplicated for purposes of sale or
for external reproduction or distribution.
Revised: January 2012
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Completed 24 April 2021

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