Fillable Accident/Illness/Incident (AII) Reporting Form & Investigation Report SECTION (Brescia University College)

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Accident/Illness/Incident (AII) Reporting Form & Investigation Report SECTION (Brescia University College)

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Accident/Illness/Incident (AII) Reporting Form & Investigation Report
FAX COMPLETED FORM (Within 24 hours)
TO: 519-661-3420 (83420)
MAIL TO: Room 4159, Support Services Building, Rehabilitation Services
SECTION #1 – Accident/Illness/Incident Reporting Form
PART A
Name of Employee: ______________________________________ Employee Number: ______________________
Contact Telephone Number of Employee: (Home)_________________________ (Cell)_________________________
Employee Group(if applicable): □ UWOSA □ PMA □ CUPE 2361 □ CUPE 2692 □ IUOE □ PSAC 610 □ SAGE □ UWOFA
□ UWOPA
□RP/TM □CW □Undergrad Student □Grad Student □Other/Visitor
Status: □RF
Type: □ Occ. Illness
□Accident □Incident □No Injury/Hazard □ First Aid □ Lost Time □ Non-Lost Time
PART B
_________________ Time: _________ a.m/p.m
Day/Month/Year
Date & Time of AII:
Date & Time AII Reported:
________________ Time: _________ a.m/p.m.
Day/Month/Year
Description of Accident/Illness/Incident:(What happened to cause the AII? What was the person doing? Was there any
equipment, people or materials involved- identify the size, weight and type)
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Part of body injured (specify left or right side):
________________________________________________________________________________________________
_ Location/Area of AII or Hazardous Situation (Building and Rm #):
_________________________________________________________________________________________________
Name & Contact Information of Witness(es): __________________________________________________________
(If there are witnesses, please include a statement from each witness)
PART C
Treatment of Injury:
1. Did the Employee/Student receive First Aid and by whom? YES □ NO □
If YES, give treatment details: _________________________________________________________________
2. Did the Employee/Student visit Workplace/Student Health? YES □ NO □
3. Did the Employee visit Hospital and/or Physician? YES □ NO □
If YES, what hospital/physician, date & time, address, phone number & give transportation details(e.g. ambulance) :
________________________________________________________________________________________________
To your knowledge, has the person had a similar disability? If YES, please explain below YES □ NO □
________________________________________________________________________________________________
CLEAR FORM
SECTION #2 – Investigation Report
PART D
Immediately investigate if any of the following occur: Fatalities, Critical Injuries, Lost Time, Occupational Illness,
Property Damage, Fire or Environmental Release
Is the employee off work due to this AII ?
□ Yes □ No
Date & Hour Last Worked: ____________________ a.m./p.m. Normal Working Hours & Days:
Day/Month/Year/Time
Employee Return to Work Date: _________________ a.m./p.m.
Day/Month/Year/Time
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Time
Hours
PART E
Contributing Factors (Check √ applicable factors):
□ Hazardous method/procedure used □ Inadequate guarding of material & equipment
□ Improper position/posture (ergonomics) □ Inadequate lighting/ventilation
□ Inadequate personal protective equipment □ Other: ____________________________________
□ Incorrect/defective tools
□ Unsafe design or construction ____________________________________
□ Poor weather conditions
□ Hazardous housekeeping or arrangement Detail Factors: ______________________________
□ Inexperience of person in the task
□ Training/job instruction inadequate
Actions and Follow up to prevent Recurrence:
□ Contact Occupational Health & Safety for assistance
□ Contact Physical Plant Department for assistance
□ Actions to improve design/procedures
□ Correct congested area
□ Repair or replace tool/equipment
□ Improve personal protective equipment
□ Install guard or safety device
□ Reinstruct person involved & provide support/coaching
□ Request Ergonomic Assessment
□ Update training
□ Refer to Rehabilitation Services
** Supervisor to provide a detailed Action Plan below**
ACTION PLAN
Action Plan(include what, why & how recommendations are
made)
Party Responsible
Completed Date
PART F
INVESTIGATED BY:
Name of Supervisor: ________________________ (print name) Telephone Number: ___________________
Supervisor Signature: _______________________________________ Date: __________________
REVIEWED BY:
Management (Department Chair or Unit Head) Signature:
__________________________________________________________ Date: __________________
Employee Signature: ________________________________________ Date: __________________
JOHSC Rep Signature: ______________________________________ Date: __________________
(if applicable)
OHS Signature: ____________________________________________ Date: __________________
(if applicable)
**FAX COMPLETED FORM TO 519-661-3420 OR EXT 83420 (ON CAMPUS)**
PART G Distribution List:
Initial - Sent Off:
Distribute copies to: 1) Workplace/Student Health Services (UCC 25) _______
(Supervisor to do) 2) Budget Unit Head/Supervisor or Chair _______
3) Employee/Student/Visitor _______
4) Originator _______
5)
Applicable Employee’s Union/Staff Group – JOHSC Rep
U
WOSA-UCC 255 _______
PMA-UCC 351 _______
CUPE 2361 FM-SSB 1320 _______
CUPE 2692 HS -Perth Hall 152 _______
UWOPA-LwH 1257 _______
IUOE _______
PSAC 610-UCC 270 _______
SAGE-STvH 3107P _______
UWOFA-ELBORN _______
6)
Unit/Department Health & Safety Officer
_______
WITNESS STATEMENT (Include for each witness when submitting AIIR)
Name of Witness: _________________________________________________________________________
Contact Information: ______________________________________________________________________
Phone/Ext: _______________________________________________________________________________
Date and Time of Accident/Incident: _________________________________________________________
Injured Worker’s Name: ___________________________________________________________________
Location of Accident/Incident: ______________________________________________________________
Your Account of the Accident/Incident:
__________________________________________________________________________________________
__________________________________________________________________________________________
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Name of Witness: _____________________________________ Date: ________________________
Signature of Witness: __________________________________
ADDITIONAL INFORMATION
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_______________________________________________________________________________________
Name: ___________________________________________ Date: ______________________________
Signature: ________________________________________
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AccidentIllnessIncident (AII) Reporting Form & Investigation Report SECTION (Brescia University College)

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Completed 29 July 2020

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