Whscc Form 7 Employers Report Of Injury
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4Page 1 of 2 – March 2013
Workplace Health, Safety & Compensation Commission
Phone: (709) 778-1000
146 - 148 Forest Rd.
Employer's Report
7
Toll free: 1-800-563-9000
P.O. Box 9000
of Injury
Fax: (709) 778-1302
St. John's, NL
Toll free fax: 1-800-276-5257
A1A 3B8
This information is collected under the authority of the Workplace Health, Safety and Compensation Act
This form must be filed within three days of injury / incident.
to determine entitlement to benefits and manage your claim.
SECTION A - GENERAL INFORMATION
WHSCC firm #
Trade name
Legal name
1
If different from trade name
Mailing address
City / Town
Street address
City / Town
Province
Postal code
if different
Site name
Site # Site location
Contacts
Name
Telephone
Fax
E-mail
2
For wage information
For details of injury
For disability, return to work
3
Worker’s last name
First name
Initial
Date of birth
yyyy/mm/dd
Gender
M
F
City / Town
Mailing address
Province
Postal code
Home telephone
Work telephone
Social Insurance Number
4
Do you regularly employ
Yes
Is the worker an owner /
Yes
less than 12 months
How long has this worker
20 or more workers?
operator of this business?
been in your employ?
more than 12 months
No
No
Contractual
Full-time
Casual
Is the worker employed as
Yes
Employment
What date was the
yyyy/mm/dd
part of a HRSDC Program?
status:
worker initially hired?
Seasonal
No
Part-time
5
What occupation was the worker performing
What are the lifting requirements of this occupation?
at the time of the injury / incident?
< 11 lbs
11-21 lbs
22-44 lbs
> 44 lbs
SECTION B - INJURY / INCIDENT INFORMATION
Date/time injury/incident was reported to employer:
6
Date / time of injury / incident
Did this injury develop
Yes
AM
hh:mm
hh:mm
over time without a
yyyy/mm/dd
yyyy/mm/dd
AM
PM
No
specific injury / incident?
PM
7
Did this injury / incident occur outside Newfoundland and Labrador?
Yes
No
To whom was the injury /
Last name
First name
Occupation
Telephone
8
incident first reported?
9
What part(s) of the worker’s
Did the worker seek
Did the worker require hospitalization
Yes
Yes
medical attention?
for more than two days?
body was affected?
No
No
10
Was the work / activity being done for
Yes
No
Did the injury / incident happen on the employer’s property or worksite?
Yes
No
the purpose of the employer’s business?
Specify where:
If no, what was the purpose?________________________
11
Describe your understanding of how the injury / incident occurred or condition developed:
12
Was the injury / incident
Motor vehicle accident
Malfunction of
Other:
Yes
If yes, tick
caused by anything
(e.g., forklift, car, truck, ATV)
product / equipment
applicable:
No
listed at right?
Person(s) not employed by the employer
Slip and fall
If yes to Question 12, was someone else involved?
Yes
No
If yes, please specify name and contact information, if available.
Last name
First name
Address
Work telephone
Home telephone
SECTION C - INJURY / INCIDENT NOTIFICATION
13
Has your occupational health and safety committee and / or representative / designate been notified of the incident / condition?
Yes
No
14
If yes, please use an additional sheet to explain your objections. Further to Section 63 of the WHSC Act, you must provide
Do you have any objections
Yes
a copy of your objections to the Commission within 10 days of the claim being reported to you. Also, you must provide the
to this claim?
No
worker with a copy of your objections.
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