Worker’s Exposure Incident Form (PEIR)

The Worker’s Exposure Incident Form (PEIR) is designed for employees to voluntarily report unexpected workplace incidents involving exposure to harmful substances. This form, identified as form 3958A, is essential for documenting incidents such as leaks, spills, ruptures, emissions, explosions, or any release of dangerous chemicals, physical substances, or contact with infectious substances or biological agents.

Key Points

• Purpose: The form helps in gathering detailed information about the exposure incident to expedite claims processing if an illness or disease develops in the future.
• Eligibility: It should be used when there is no lost time and no illness as a result of the incident. If medical treatment is required due to the exposure, a Report of Injury/Disease should be filed instead.

The Worker’s Exposure Incident Form (PEIR) is crucial for documenting unexpected workplace exposure incidents. Follow these steps to complete the form accurately:

Step-by-Step Instructions

Your Information

1. • Last Name: Enter your surname.
   • Given Name: Enter your first name.
   • Maiden Name: If applicable, provide your maiden name.
   • Address: Include your complete residential address.
   • City/Town: Specify your city or town.
   • Province: Indicate your province.
   • Postal Code: Enter your postal code.
   • Telephone: Provide your contact number.
   • Sex: Check the appropriate box (Male/Female).
   • Date of Birth: Use the format (dd/mm/yyyy) to fill in your birth date.

Your Employer’s Information

1. • Employer’s Name: Provide the name of your employer at the time of the incident.
   • Date of Hire: Indicate when you started working with this employer.
   • Nature of Employer’s Business: Briefly describe the type of business your employer is engaged in.
   • Your Occupation/Job Title: State your current job title.
   • Employer’s Address: Enter the full address of your workplace.
   • City/Town: Specify the city or town of your workplace.
   • Province: Indicate the province of your workplace.
   • Postal Code: Provide the postal code of your workplace.
   • Location of the Incident: Detail the specific location where the incident occurred.

Details of the Incident

1. • Date of Exposure: Use the format (dd/mm/yyyy) to specify the date of exposure.
   • Time of Exposure: Mark whether the exposure happened in the AM or PM.

For Exposure to Infectious Substances (Section A)

1. • How You Came into Contact: Check the appropriate box (Cut or scrape, Body fluid splash, Cough, sneeze, Other).
   • Source of Exposure: Describe the source of the infectious substance.
   • Area of Body Affected: Indicate which part of your body was affected.
   • Suspected Infectious Substance: Check the suspected substance (e.g., Tuberculosis, Meningitis, Rabies, etc.).

For Exposure to Chemical or Other Workplace Substances (Section B)

1. • Describe the Incident: Check the appropriate box (Leak, Spill, Explosion, Other) and provide details.
   • Location and Duration: Describe where you were and how long you stayed in the affected area.
   • Personal Protective Equipment: List any protective gear you were wearing at the time.

Signature and Consent

1. • Signature: Print and sign your name, or type and upload your signature if submitting online.
   • Date: Use the format (dd/mm/yyyy) to indicate the date you completed the form.

Submission

1. • Online: Upload the completed form at wsib.ca/reportupload.
   • Mail: Send to WSIB, 200 Front Street West, Toronto, Ontario, M5V 3J1.
   • Fax: Send to 416-344-4684 or 1-888-313-7373.

Additional Notes

• If you experience any illness or require medical treatment due to the incident, file a Report of Injury/Disease instead.
• For assistance or to report an exposure by telephone, contact WSIB at 1-800-387-0750 (toll-free) or 416-344-1000 (local).

By carefully following these instructions, you ensure that all necessary information is provided, facilitating a smooth and efficient processing of your report.