Accident Report Form

Employees, Students, and Others

General Information

Employee/Student/Other Information

Location of Accident

Accident Information















































Accident Description

You can upload multiple images by holding "ctrl" while selecting the image(s). All images that will be associated with this report will then be displayed below the file seletor.

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Please note, IMMEDIATELY call 1 800 222-9775 to report the following incidents involving Employees:

  • A loss of consciousness
  • Amputations
  • Fractures (other than fingers and toes)
  • Burns requiring medical attention beyong first aid treatment
  • Loss of vision in one or both eyes
  • Deep lacerations requiring medical attention beyond first aid treatment
  • Worker admission to a hospital as a an in-patient
  • Fatalities
  • Any accidental explosion or exposure to a biological, chemical or physical agent, whether or not a person is injured
  • Any catastrophic event or equipment failure that results, or could have resulted in an injury
  • Within three days of notification if the scenario does not fit any of the descriptions above.

UNB and Environmental Health and Safety are committed to protecting personal information.
The personal information collected on this form will only be used in relation to incident reporting, employee files and will only be accessed by the necessary administrators and those necessary to ensure a safe environment at UNB.
The information collected on this form may be anonymized for statistical, program development and safety purposes.
This information is being collected under the authority provided for in the New Brunswick Right to Information and Protection of Privacy Act, the Occupational Health and Safety Act and the Workers' Compensation Act.
If you have any privacy concerns in relation to this form or for more information on the protection of personal information at UNB, please contact the University Secretariat, University of New Brunswick, PO Box 4400, Fredericton, NB, E3B 5A3 http://www.unb.ca/secretariat (506) 453-4613.

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