TXSNOW

ACCIDENT REPORT

Do you have another employer? /

Employee number

Date and time of Accident ：

Date

Time

Was the injury sustained outside your province of residence? If YES, please indicate where you "Elect" to open your claim

Please describe the exact circumstances of the event

In case of occupational disease, describe when and how exposure occurred /

Please state ALL injuries reported, indicated right or left, if applicable

Did Instructor attend a physician or qualified practitioner or clinic? Does the Instructor see a doctor or a qualified therapist or clinic?

How was injury sustained? What caused the injury?

Last Name and First Name

Address ：

When was the injury first reported to the employer?

Was Ski Patrol called? / Whether to report to the ski resort safety officer ？

Did instructor receive First Aid? Do the Instructors need first aid?

Did the Instructor go to the hospital？

Type of injury sustained? / What type of injury?

Area of injury - please check all that apply

Weather ：

Temperature (Celcius) ：

Other Conditions ：

Trail Name

Location

Visibility ：

Snow ：

Ski Area

Location of student

Location of Instructor

Other

Was any other action taken? If YES, please specify. /

Witness Name

Witness Telephone

Witness Address