Report It! - UBCP ACTRA

Date of Accident/Incident (dd/mm/yyyy)*

Time of Accident/Incident*

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Name of Production*

Performance Category*

Was the event an Accident or an Incident – Please choose one of the following*

Type of Injury*

Type of Injury if you chose "other" above. Please describe the type of injury

Mechanism of injury (or near miss) (i.e. fall, exposure to hazardous material, driving etc.)*

Was the incident reported?

If yes – indicate who it was reported to (i.e. FirstAid/Craft Services, Wrangler, A.D., Stunt Cordinator, Family physician, co-worker, etc.)

Was a written report completed on set?*

If yes please indicate who completed the report (i.e. FirstAid/Craft Services, Wrangler, A.D., etc.)

Did you miss any work as a result of this injury?*

Did you receive first aid/medical treatment

If yes where and from whom

Your full name*

Please note this report – including your name – will be held in confidence unless you authorize us to release this information.

Are you a UBCP member*

If yes please put your UBCP Member number

Email*

Phone*

Have you made a WCB Claim?*

Have you informed your benefits provider? (UBCP/ACTRA Members will be with AFBS or MBT)*

Is there anything else you would like to comment on about this accident/incident – such as how it was handled or what caused it to happen.

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UBCP/ACTRA Accident-Incident Report