Complete the form

If you prefer, you can use the dynamic PDF form. You must download the form Report an accident – PDF (729 KB) before opening.

If the report concerns petroleum equipment, please use the form entitled Relevé d’événement des équipements pétroliers [Fr] – PDF (516 KB).

The fields preceded by an asterisk ( * ) are mandatory.

2. Date of the accident observed

Indicate, to the best of your knowledge, the date and time where the accident occurred.

Date (day/month*This field is mandatory./year*This field is mandatory.)

Hour

3. Description of the accident

Yes

No

I do not know

*This field is mandatory.Describe in a few words the facts you wish to report.

4. Your details

Last name

First name

Name of the organization you represent (if any)

Telephone number (555 666-7777)

Extension

Other telephone number (555 666-7777)

Extension

E-mail address

Please confirm e-mail address

5. Do you authorize the Régie du bâtiment du Québec (RBQ) to communicate with you?

If you check “No”, please make sure that you have provided a complete set of information, in order that your reporting may be processed.

Yes

No

Print the form before sending it and keep your copy for reference.

1. Scene of the accident