Fillable Worker's Exposure Incident Form

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Worker's Exposure Incident Form

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Country of origin: CANADA
File type: PDF

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Worker's Exposure
Incident Form
The attached Worker's Exposure Incident Form (form 3958A) is intended for voluntary use when an unplanned
workplace incident exposure has resulted from a leak, spill, explosion, release, or an unexpected contact with a
chemical or other substance. The event may have exposed workers to an infectious, chemical or other substance.
The purpose of this form is to obtain information about the exposure incident experienced by the worker should an
illness or disease occur in the future.
The Worker's Exposure Incident Form should be completed if you have experienced an unplanned
workplace exposure where there has been:
no lost time
•
no illness
•
If you are experiencing any illness needing medical treatment, (such as diagnostic tests,
prescribed medication or ongoing treatment) please complete a Worker's Report of
Injury/Disease (Form 6).
Forms should be completed and forwarded to:
By Mail By Fax
Workplace Safety and Insurance Board
Occupational Disease and Survivor Benefits Program
200 Front Street West, 4 Floor
Toronto, Ontario M5V 3J1
416-344-4684
1-888-313-7373
th
To report an exposure incident by telephone or for questions concerning the Worker’s Exposure Incident
Reporting Form, please contact us at:
Toll Free:
Local Dialing:
Website:
TTY:
1-800-387-0750
416-344-1000
www.wsib.on.ca
1-800-387-0050
3958A (07/16)
Worker's Exposure
Incident Form
WSIB Use Only
Firm No. Rate No. Classification Unit Code Reference No.
The following information will assist the Workplace Safety and Insurance Board (WSIB) in recording a workplace exposure incident. Please
provide as much detail as possible to ensure that the incident is accurately recorded.
Your Information
Last Name Given Name Maiden Name (if applicable)
Address (street address/city/town/province)
Postal Code
Telephone Sex Date of Birth (dd/mm/yyyy)
male female
Your Employer's Information
Employer's Name (at time of incident) Date of Hire (dd/mm/yyyy)
Describe the Nature of your Employer's Business
Your Occupation/Job Title
Employer's Address (street address/city/town/province)
Postal Code
Location of the Incident
Details of Incident
Complete Section A for an exposure to an infectious substance, or
Section B for an exposure to chemical or other workplace substances.
Date of Exposure (dd/mm/yyyy) Time of Exposure
Section A - (Infectious Substance)
Please describe how you came into contact with the infectious substance (please check):
other (specify)
cut or scrape cough, sneeze
body fluid splash
Source of exposure Area of Body Affected
What infectious substance is suspected? (please check):
campylobacter
hepatitis anthrax
tuberculosis rabies
meningitis
don't know other (specify):
salmonella shingles
scabies
If you experienced any illness related to this incident, please complete a Worker's Report of
Injury/Disease (Form 6). For further information, please contact 1-800-387-0750.
3958A (07/16) Page 1 of 2
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Worker's Exposure
Incident Form
Reference No.
Details of Incident ...(Continued)
Date of Exposure - (dd/mm/yyyy) Time of Exposure
Section B - (Chemical or Other Workplace Substances)
Please describe, in detail, what occurred: (please check):
leak spill explosion other (specify)
Please describe where you were at the time and how long you were in the affected area.
(If it would be helpful, attach a diagram to describe the event or another sheet for added information).
What personal protective equipment were you wearing at the time?
In the event that this exposure results in an illness that entitles you to benefits under the Workplace Safety and Insurance
Act (the Act), by signing this form, you consent to the release of functional abilities information as required in section 22(5)
of the Act, in the event there is a right to benefits.
Signature Date
SUBMITTING THE EXPOSURE INCIDENT FORM TO THE WORKPLACE SAFETY AND INSURANCE BOARD
If your employer is reporting the exposure you may provide this form to them to include with their submission. You may also choose to
forward the form directly to the WSIB.
By Mail By Fax
Workplace Safety and Insurance Board
Occupational Disease and Survivor Benefits Program
200 Front Street West, 4 Floor
Toronto, Ontario M5V 3J1
416-344-4684
1-888-313-7373
th
Personal information about you will be collected throughout your claim under the authority of the Workplace Safety and Insurance Act, 1997. Your personal
information will be used to administer your claim(s) and programs of the Board. Medical and non-medical information is collected from health care providers,
vocational agencies, labour market service providers, employers, witnesses, Canada Revenue Agency (CRA), and others as required. Your Social Insurance
Number is used to register claims, identify workers and to issue income tax statements and is collected under the authority of the Income Tax Act.
Information may only be disclosed to the employer, external medical consultants, external service providers, researchers, third parties for cost recovery
purposes and others as authorized by the Workplace Safety and Insurance Act and the Freedom of Information and Protection of Privacy Act. Your name
and telephone number may be disclosed to third parties conducting satisfaction surveys and focus groups. Incoming and outgoing calls may be recorded for
quality assurance purposes. Questions about this collection should be directed to the decision maker responsible for your file or by calling 1-800-387-0750.
3958A2 Page 2 of 2
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Worker's Exposure Incident Form

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Completed 19 February 2021

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