Ontario Incident Report Form

Data Fields with a red border must be completed before FirstReport Online can create a new incident record.

Last Report Generated (click to view or download)
 Employer Name  
 Location Where Employed  
 Department Where Employed  
 Hidden Record ?
 Record Marked for Delete ?

     Basic Case Information
 Report Number  
 Date Of Injury  
 For Information Only
 Claim Status
 WSIB Claim Number
 Social Insurance Number  -   - 
 Employee First Name
 Employee Middle Initial
 Employee Last Name

     Employee Information
 Update from Employee Data Table    (to update save record)

 Employee Address
 Employee City
 Employee Province
 Employee Postal Code  - 
 Employee Phone  )   - 
 Employee Date Of Birth
 Worker Reference Number
 Miner Certificate Number
 Occupation Description
 Years Experience in Occupation
 Date Hired
 Preferred Language
 Other Language
 Is employee (sub) contractor, independent operator, owner, executive, spouse or relative

     Incident Description
Type Of Injury
Part Of Body Injured
Side Of Body Injured
Cause Of Injury
Location Of Injury
 Occur on Employer Premises ?
 Where Event Occurred
 Postal Code  - 
Activity engaged in when injury occurred (150 characters max)
Equipment, Materials, Chemicals Used When Injury Occurred
(150 characters max)
How Injury Occurred (150 characters max)
 Time Employee Began Work
 Time Of Injury
 Date Reported To Employer
 Time Reported To Employer
 Date Last Worked
 Time Last Worked
 Last Work Day Begin
 Last Work Day End
 Date Returned To Work
 Time Returned To Work
 Earnings Last Day
 Normal Earnings
 If worker could have returned earlier, provide details
 Injury Reported To
 If report delayed, provide reason
 Witness Name 1
 Witness Address 1
 Witness Phone 1
 Witness Name 2
 Witness Address 2
 Witness Phone 2
 If fatal, give date of death
 If providing advance to cover disability, give details
 If advance is mailed to a different address, please provide
 Prior Similar Injury ?
Similar Injury Detail (100 characters max)
 Other Individual Involved ?
Other Individual Involved (100 characters max)
If equipment or motor vehicle involved, provide detail (100 characters max)
 Doubt Injury Is Work Related ?
 Doubt Work Related Detail
 Doubt Work Related Letter Attached ?
 Responsible for RTW (name/phone)

     Temporary Disability / Earnings Information
 Employee Absent From Work ?
 Assume Other Duties ?
 Reduced Earnings ?

Earnings Information - Do not complete the remainder of this section if you answered no to all of the three questions above.

 Rate Of Pay
 Pay Period
 Total Weekly Pay Hours
 Average Weekly Pay Hours
 Employee Schedule Change ?
 Net Claim Federal (code or amount)
 Claim Code Federal
 Net Claim Provincial (code or amount)
 Claim Code Provincial
 Benefit Plan Continue ?
 Benefit Plan Multi Employer ?

 Work Days - Regular Schedule
(enter hours per day)
Mon Tue Wed Thu Fri Sat Sun

 Check all of the additional earnings that apply.
If a benefit will not continue, provide the value, if known.
  Additional Earnings Continue ? Value Per
 Vacation Pay
 Production Bonuses
 Profit Sharing
 Room, Board, Vehicle
 COL, Shift Diff, Lead Hand
 Tips, Gratuities
 Unemployment Insurance

 Type of Employment - check all that apply
Full Time Part Time Casual Seasonal Apprentice Student Learner Other (explain)

 Employee Worked After First Absence From (Date)
 Employee Worked After First Absence From (Time)
 Employee Worked After First Absence To (Date)
 Employee Worked After First Absence To (Time)

     Medical Treatment
 Initial Treatment
 Treated In Emergency Room
 Hospitalized Overnight
 Physician Name
 Physician Address
 Physician City
 Physician Province
 Physician Postal Code  - 
 Physician Phone  )   - 
 Hospital Name
 Hospital Address
 Hospital City
 Hospital Province
 Hospital Postal Code  - 
 Hospital Phone  )   - 
 Continuing Treatment Name
 Continuing Treatment Address
 Continuing Treatment Phone

     OSHA Recordability
 Auto Calculate Days Away or
 Restricted Time Days
 Number of Days Away
 Number of Restricted Work Days
 Use Privacy Case Test
 Privacy Case
 Use OSHA Recordability Test
 OSHA Recordable

     Employer/Preparer Information
 Employer Fax Number
 Employer Firm Number
 Employer Rate Number
 Employer Classification Unit Code
 RTW Program ?
 Employee Represented by Union ?
 Date Prepared
 Preparer's Name
 Preparer's Title
 Preparer's Phone  )   - 

     Identification Code
 Code Description  
 Code Value  

     User Defined Fields
 Employee status
 User Defined Text 2
User Description (100 characters max)
 User Defined Date 1
 User Defined Date 2
User Defined Comment (300 characters max)

 Export Data Report Type

Report History (click to view or download)