Canada Occupational Health and Safety Regulations
Version of the schedule from 2025-03-26 to 2026-03-17:
SCHEDULE II(Subsection 15.10(2))
 | Employment and Social Development Canada | Emploi et Développement social Canada | PROTECTED B WHEN COMPLETED |
Reporting Year:
EMPLOYER’S ANNUAL HAZARDOUS OCCURRENCE REPORT (Regular/Offboard)
Instructions on how to complete the form can be found at Canada.ca/workplace-health-safety-annual-reports
| Employer’s legal name | Business number | |
| Employer’s operating name (if different from above) | ||
| Mailing address | ||
| Name of contact person | Business telephone | |
| Mailing address | ||
| Signature | Date | |
| Work Place Information | Injury Data | Employment Data | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Work Place ID | Work Place Name | Headquarters (Y/N) | Work Place Reference Number | Address (Street, City, Province, Postal Code) | Number of Disabling Injuries | Number of Deaths | Number of Minor Injuries | Number of Other Hazardous Occurrences | Total Number of Hours Worked | Total Number of Employees | Number of Office Employees | In Operation (Y/N) | Date Ceased YYYY-MM-DD |
| Comments: | |||||||||||||
| Comments: | |||||||||||||
| Comments: | |||||||||||||
| Comments: | |||||||||||||
| ESDC-NHQ LAB1009 E |  |
- SOR/89-479, s. 1
- SOR/2025-79, s. 4
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