Employer’s exposure incident reporting form (PEIR)
You should use the Employer’s Exposure Incident Form (form 3959A) to voluntarily report an unexpected workplace
incident exposure from a leak, spill, rupture, unanticipated emission, explosion or a release of a dangerous chemical or
physical substance or contact with an infectious substance or biological agent.
Submitting this form will help us gather information about the exposure incident so we can process a claim faster if one or
more people experience an illness or disease in the future.
You should complete this form if you are a supervisor and/or the Joint Health and Safety Committee Representative. If you
experienced the exposure, you should submit a Worker’s Exposure Incident Form (form 3958A).
You should only submit the Employer’s Exposure Incident Reporting Form for an unexpected workplace exposure event
where there has been:
•
no lost time
•
no illness
If the person is experiencing any illness and needs medical treatment, (e.g., diagnostic tests, prescribed
medication or ongoing treatment) as a result of the incident, you should log into our online services for
businesses and file an Employer’s Report of Injury/Disease.
Once you complete the form, you can submit it online. Upload at wsib.ca/reportupload.
To report an exposure incident by telephone or for questions concerning the Employer’s Exposure Incident Reporting
Form (PEIR), please call us at:
Toll free:
1-800-387-0750
Local dialing:
416-344-1000
TTY:
1-800-387-0050
Contact accessibility@wsib.on.ca if you require this communication in an alternative format.
200 Front Street West, Toronto, Ontario, M5V 3J1
Upload online: wsib.ca/reportupload | Toll free: 1-800-387-0750 | TTY: 1-800-387-0050 | Fax: 1-888-313-7373
3959A (11/20)
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Employer’s exposure incident reporting form (PEIR)
The information you provide will help us record the exposure incident. Please provide as much detail as possible.
Employer’s information
Employer’s name (at time of incident)
TEMPUR-SEALY CANADA LTD
Firm no.
030158EB
Class/subclass
328
NAICS code
Employer’s address for correspondence
145 MILNER AVENUE
City/Town
SCARBOROUGH
Province
ON
Postal code
M1S R31
Address for location of incident
145 MILNER AVENUE
City/Town
SCARBOROUGH
Province
ON
Postal code
M1S 3R1
What is the nature of your business?
MATTRESS MANUFACTURER
Please list all workers involved in the exposure incident (use additional sheet if necessary)
Last name
BURINAGA
Address
1.
36 WILSONGARY CIRCLE
Given name
Date of birth (dd/mm/yyyy)
Date of hire
JEROME URETA
4/18/78
21/09/2015
Postal code
L1T 0G6
City/Town
AJAX
Telephone
(647) 215-0411
Last name
KANDIAH
Address
2.
739 HAMMERSLY BLVD
Sex
3.
Date of hire
THANGESWARAN
City/Town
MARKHAM
01/01/1963
Province
ON
06/04/1995
Postal code
L6E 2B2
Sex
male
Given name
JORGE
Telephone
(416) 759-0719
Sex
Telephone
416-744-1024
female
Social Insurance No.
505 002 980
Date of birth (dd/mm/yyyy)
31/05/1964
City/Town
TORONTO
Kishan
Address
4.
52 Elana Drive
Social Insurance No.
561 984 006
Date of birth (dd/mm/yyyy)
Address
107-600 EGLINTON AVE. EAST
Last name
female
Given name
Telephone
(905) 471-4137
Last name
BERNAL
male
Province
ON
male
Given name
Rajinder K
City/Town
Toronto
Sex
male
Date of hire
25/04/2000
Province
ON
female
Postal code
M4P 1P3
Social Insurance No.
537 318 776
Date of birth (dd/mm/yyyy)
Date of hire
07/11/1962
Province
ON
22/07/2008
Postal code
M3N 2C2
female
Social Insurance No.
490 051 687
If more space is required, please attach a separate form.
If you have your own incident report form and submit it along with this page, completion of page two is not required.
You may, however, be contacted for further information.
Contact accessibility@wsib.on.ca if you require this communication in an alternative format.
200 Front Street West, Toronto, Ontario, M5V 3J1
Upload online: wsib.ca/reportupload | Toll free: 1-800-387-0750 | TTY: 1-800-387-0050 | Fax: 1-888-313-7373
3959A (11/20)
Page 2 of 3
Firm number
030158EB
wsib.ca
Details of incident
Complete Section A for an exposure to an infectious substance, or
Section B for an exposure to chemical or other workplace substances.
Section A - (Infectious substance)
Date of exposure (dd/mm/yyyy)
12/03/2021
What type of exposure was involved? (please check):
Cut or scrape
Body fluid splash
unknown
Cough, sneeze
Source of exposure
COVID 19
Time of exposure
PM
AM
Other (specify):
Area of body affected
RESPIRATORY TRACT
What infectious substance is suspected? (please check):
Tuberculosis
Meningitis
Rabies
Hepatitis
Anthrax
Salmonella
Scabies
Shingles
Don’t know
Other (specify): COVID 19
Date of exposure (dd/mm/yyyy)
Section B - ( Chemical or Other
Workplace Substances)
Please describe, in detail, what occurred (please check):
Leak
Spill
Explosion
Campylobacter
Time of exposure
PM
AM
Other (specify):
What chemical or other workplace substance was the worker exposed to?
Please describe where the worker(s) were at the time and how long they were in the affected area.
(What personal protective equipment was being worn by worker(s)? What emergency measures were taken after the
incident? What was done to control the situation? If it would be helpful, attach a diagram to describe the event or another
sheet for added information).
PLANT FLOOR. PPE WAS INPLACE. (FACE MASKS WERE WORN).
PLANT IS SANITIZED TWICE DAILY WITH FOGGING DISINFECTANT.
Were any WSIB claims for an illness, condition or disease related to this incident?
Yes
No
Was a formal report of the incident made to the Ministry of Labour or the Ministry of the Environment?
Yes
No
Did Ministry officials come to the premises because of the incident?
Yes
No
Is any information available about the substance(s) involved in the incident such as MSD’s
Yes
No
Was environmental sampling done following the incident?
Yes
No
(If yes is answered to any of the following, please provide a copy)
Name of person completing report
VERONIKA GOUSSEVA
Official title
PLANT PAYROLL ADMINISTRATOR
Signature (print, sign and return to the WSIB or type and upload)
Telephone
Date (dd/mm/yyyy)
VERONIKA GOUSSEVA
416 332-4843
31/03/2021
Submit the exposure incident form to the WSIB
If the person(s) experiencing the unexpected workplace exposure incident are reporting their exposure, please attach all
copies of the Worker’s Exposure Incident Forms and forward to:
3959A
Online
By mail: WSIB 200 Front Street West, Toronto, Ontario M5V 3J1
Upload online at wsib.ca/reportupload.
By fax:
416-344-4684 | 1-888-313-7373
Page 3 of 3