TXSNOW

ACCIDENT REPORT

Do you have another employer? / 您是否有其他的雇主？

Employee number / 员工号

Date of Accident / 意外日期和时间：

Date

Time

Was the injury sustained outside your province of residence? If YES, please indicate where you "Elect" to open your claim 受伤是否发生在居住省外，如果是的话，请填写事故发生省

Please describe the exact circumstances of the event / 请详述具体事故如何发生的

In case of occupational disease, describe when and how exposure occurred / 如果是职业病，请详述具体如何发生的

Please state ALL injuries reported, indicated right or left, if applicable / 请列出所有报告的伤害，如果适用，请指明是右边还是左边。

Did Instructor attend a physician or qualified practitioner or clinic? 教练是否去看医生或合格的治疗者或诊所？

How was injury sustained? 受伤是什么造成的？

Last Name and First Name / 姓和名

电邮

Address / 住址：

Injury was first reported to employer on / 报告受伤给雇主日期

Was Ski Patrol called? / 是否报告雪场安全员？

Did instructor receive First Aid? 教练是否需要急救？

Did Instructor go to hospital？教练是否去医院？

Type of injury sustained? / 什么类型的伤？

Area of injury - please check all that apply / 受伤部位，请给出所有相关的部位:

Weather / 天气：

Temperature (Celcius) / 温度（华氏度）：

Other Conditions / 其他情况：

Trail Name / 滑道名字

Location / 位置

Visibility / 能见度：

Snow / 雪况：

Ski Area / 滑雪位置

Location of class / 学生位置

Location of Instructor / 教练位置

Other / 其他

Was any other action taken? If YES, please specify. / 是否当场采取其他措施，如果是的话，请详述

Witness Name / 见证人名字

Witness Telephone / 见证人电话

Witness Address / 见证人地址