January 6, 2016
Accident Investigation and Reporting
The JHSC will investigate all accidents involving serious injuries within seven days. A member of the JHSC will go out to the accident scene and investigate the incident, talk to employees, find hazards and fill out the Accident Investigating and Reporting Form. JHSC will follow up and make recommendations for corrective actions. They will notify WSIB of any type of injuries, lost time or not and fill out Form 7 and notify the MOL and MOE when needed.
Reporting Form
Worker Information
q Employee             q Sub-Contractor  
Last Name   First Name  
SIN #   Years of Experience  
Date of Birth   Date of Hire  
Occupation at time of Injury  
Details of Injury / Disease   Employee’s Action
Date of Injury   Date reported  
Time of Injury am / pm Time reported am / pm
Date last worked   Normal working hours From          to
Hour last worked am / pm  
What is the injury / disease?  
What happened to cause injury / disease? Please explain in detail how the injury happened  
Who did you report the injury / disease to?  
Where were you when injured / diseased?  
Did anyone witness your injury / disease?  
To your knowledge have you had a previous similar injury / disease? (if yes, please explain) Yes       No
What actions do you suggest should be taken to prevent similar accidents in the future?  
Employee’s Name   Date  

Supervisor’s Action
To your knowledge has this worker had a previous similar injury / disease?   Yes         No
Do you have any reason to doubt that the injury / disease is not work related?  (if yes, please explain)   Yes         No
Follow up to accident by supervisor  
Follow up to accident by Joint Health & Safety  
Joint Health & Safety members  
Signatures of the JHS members  
What actions should be taken to prevent similar accidents in the future?  
Supervisor’s Name   Date  

  • All employees receive handout every year
  • All management and supervisor are notified of any injuries suffered to their employees
  • Management and JHSC keep up to date on safety issues and WSIB regulations
  • Member of the Landscape Ontario/ WSIB Safety Group
  • Employees read policy
  • JHSC and management review every spring of every year
  • JHSC reviews every spring of every year and make changes and or recommendations as needed