Injury / Incident Reporting Form

Injury / Incident Reporting Form

All community members must complete and submit this form as soon as possible following an Injury / Incident or Near Miss. The personal information provided in this form is collected pursuant to the Occupational Health and Safety Act and the Workplace Safety and Insurance Act, 1997. The information collected from this form will be used for the purpose of reporting accidents/ incidents, administering investigations, conducting/managing a WSIB claim, and complying with legal requirements.

If you have questions regarding the Incident Report Form, please contact the Health and Safety Department at healthandsafety@algomau.ca.

Section 1 - Details of Reportee

Details of person completing this report

First Name*

Your First Name

Last Name*

Your Last Name

Student /Staff/Faculty Number

Campus*

Campus or Site where the injury/incident occurred:

Select or enter value

Is this a Security related incident?*

Yes

Are You*

Are you reporting this injury/incident for yourself

Yes

Section 2- Details of the Security Report

Nature of Incident Report *

Briefly describe the nature of the incident report

Details of the incident reported by the Security*

Briefly explain the incident from Security's Report

Section 2 - Details of Individual (Injured employee or person involved in an incident)

All employees / person reporting shall fill out this section to the best of their recollection of events leading up to and including details of the injury / incident.

Employment Status*

Are you/affected person a(n):

Select

Department*

Current department?

Select

Position*

What is your/affected person's current position (if applicable)?

Time in current role

How long have you/affected person been in the current role? (in Years)

Select

Union/Collective Agreement*

What union/collective agreement is your/affected person's position covered by (if applicable)?

Select

Supervisor's Email*

Your/Affected Person's direct manager/supervisor's email:

Witnesse(s)*

Is there any other person(s) who witnessed the event?

Yes

Section 3 - Witness Details

Witness(s) Name*

Please provide their full name(s), position(s) (if applicable), and phone number(s).

Section 4 - Injury/Incident/Near Miss details

Reported to Manager/Supervisor*

Was this incident reported to your/affected person's immediate supervisor/manager/faculty?

Select

Date when reported*

Date when injury/incident was reported?

Date of Injury/Incident*

Date when injury/incident occurred?

Type of Injury/Incident*

Select

Description of First Aid

Cut/puncture/abrasion/lacerations - Cuts that do not involve fat or muscle tissue (superficial), are not bleeding heavily, are less than 1/2 inch long - First Aid only

Description of Medical aid /hospitalization

Cut /puncture/laceration or other requiring hospitalization

Description of Critical Injury

If this is a Critical Injury, please

Step 1: Call 911

Step 2: Administer first aid to the injured employee

Step 3: Secure and manage the scene (clear employees and unessential persons from area, control or eliminate sources of danger, DO NOT DISTURB SCENE)

Step 4: Reporting (Safety Committee, Union, MOL)

Step 5: Conduct an investigation

Definition of Critical Injury

For the purposes of the Act and the Regulations,

“critically injured” means an injury of a serious nature that,

(a) places life in jeopardy,

(b) produces unconsciousness,

(d) involves the fracture of a leg or arm but not a finger or toe,

(e) involves the amputation of a leg, arm, hand or foot but not a finger or toe,

(f) consists of burns to a major portion of the body, or

(g) causes the loss of sight in an eye. R.R.O. 1990, Reg. 834, s. 1.

Injury/Incident Occurrence Location*

Where did the injury/incident occur:

Select

Please specify the location on the Brampton Campus*

Select or enter value

Specific Location*

Specific location of where the injury/incident occured. Please give as much detail as possible - the exact location, time, names and contact information for witnesses (if applicable).

Description of Injury/Incident*

Briefly, but precisely describe the injury/incident.

Please give as much detail as possible and include all relevant information

Training*

Was the individual trained to complete the tasks given at the time of the incident?

Yes

Not Applicable

Job/Task*

At the time of the event, was the job/task being done in the usual way?

Yes

Not Applicable

Explain*

Explain why the job/task was not being done in the usual way. What was different, could be internal/external circumstances eg: weather, lack of training......

Material/Equipment used*

Please identify the size, type, and weight of any materials/equipment involved in the event (If applicable)

Which side?*

Which side did the injury occur?

Left Side

Right Side

Not Applicable

Similar injuries in the past*

Have you experienced a similar injury to this body part(s) previously?

Yes

Section 5 - Details of similar injury in Past

Details of past injuries*

If yes, please describe where, when, and how it happened.

Section 6 - Medical Treatment Details

Medical Attention Required*

Are you planning to or have you already sought medical attention for this accident/incident?

Yes

When?

If yes, when did you seek medical attention?

Treatment Details

Specify details of treatment received

WSIB Form 8

Have you provided WSIB Form 8 to your supervisor/manager?

Yes

Not Required

Section 7 - Corrective Actions

Corrective Actions*

Are corrective/further actions required with regard to this incident?

Yes

What Actions*

Please specify what actions have/need to be implemented (eg. safety talk, coaching..)

Explain why no Corrective Action is required*

Please specify why no corrective action is required

Who is responsible to implement these corrective actions*

Individual responsible for completing the corrective action

Section 8 - Preventative Actions

Preventative Actions*

Are preventative actions required with regards to this incident?

Yes

What Actions*

Please specify what actions have/need to be implemented (eg. safety talk, coaching..)

Explain why no Preventative Action is required*

Please specify why no preventative action is required

Who is responsible to implement these preventative actions*

Individual responsible for completing the preventative action

File Upload

You may upload a copy of Form 8, Pictures, or any supporting documents here:

Drag and drop files here or

Section 9 - Sign Off

Sign off*

Further action/follow-up/investigation required?

Yes

Send me a copy of my responses