Fillable University of Guelph - Illness or Injury Incident Report Form

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University of Guelph - Illness or Injury Incident Report Form

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The University of Guelph - Illness or Injury Incident Report Form form is 2 pages long and contains:

  • 3 signatures
  • 120 check-boxes
  • 49 other fields

Country of origin: CANADA
File type: PDF

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This form must be initiated and faxed/ emailed within 24 hours of the
Supervisor learning of the incident. Fax to 519-780-1796 or email to
ohw@uoguelph.ca. Submit additional information as available.
THIS SECTION TO BE COMPLETED BY OR FOR THE AFFECTED PARTY
Who was the
affected person?
Last Name:
First Name:
Initial:
Phone or Extension:
EMPLOYEE
STUDENT
VISITOR
VOLUNTEER
CONTRACTOR
Occupation, if applicable:
Department:
Union/Bargaining Group:
Name of Supervisor:
Phone or Extension:
Name of Dept. Head:
Date & Time of Incident:
Date Reported to Supervisor:
Date Submitted:
Slip, Trip or Fall
Struck by/against Object
Electrical Shock/Burn Exposure to possible
Needle/Sharp/Puncture/Cut hazardous/infectious material
Loss of Consciousness Animal Bite
/Sting/Scratch
If Slip or Fall describe footwear:
Muscle Strain
Repetitive Strain
Other
Description of Incident:
Witnesses (Name/Phone Number):
Where did
the incident
occur?
Guelph Campus Kemptville Campus
Ridgetown Campus Research Station:
Other
Building Name:
Cafeteria
Classroom
Hallway
Kitchen
Lab
Stairwell
Office
Washroom
In vehicle
Stairs
Loading Dock Parking Lot Walkway Other
What was the injury: Select part of body and indicate Right (R) Left (L), both (B)
or Quantity Injured in the box:
Head Teeth Pelvis Elbow Upper Back Knee Toes
Face Neck Shoulder Wrist Lower Back Lower Leg
Eye Abdomen Upper Arm Hand Hip Ankle
Ear Chest Lower Arm Fingers Upper Leg Foot
Did you see a medical professional?
No
Yes If yes, Date of Visit:
If yes, Nam
e, Address and Phone Number of Medical Professional:
Treatment of Injury:
Occ Health / Dept. First Aid Emergency Room
Physician /Clinic No First Aid Req’d
Student Health Services
Continued on Page 2
Injury
First Aid
No First Aid
Health Care (Medical Aid)
No Injury
Hazardous
Situation
ILLNESS or INJURY INCIDENT REPORT
Revised September 2019 Incident Report Page 1
Complete Workplace Harassment Reporting Form
for reporting harassment in the workplace or
Workplace Violence Reporting Form, for reporting
workplace violence
THIS SECTION TO BE COMPLETED WITH OR BY THE SUPERVISOR
Contributing Factors: What conditions contributed to the incident?
Operating W/O Authority
Inadequate Work Procedure
Failure to Lockout
Insufficient Training
Unsafe Equipment
Inadequate Housekeeping
Improper Position/Posture
Inadequate Illumination
Infraction OR Unsafe Practice
Failure of Personal Protective Equipment
Not or Improperly Guarded
Hazardous Environmental Condition
Inclement Weather
Other
Explanation of Contributing Factors:
Details of Property Damage (if any):
To your knowledge, has the employee reported a previous similar injury or similar hazardous situation before?
No Yes
Corrective Measures: Actions taken to prevent a reoccurrence (Check all that apply):
Control Operation / Access
Improve Work Procedure
Apply Lockout / Tag-out
Provide Training
Repair / Replace Equipment
Perform Housekeeping
Ergonomic Assessment
Job Safety Analysis
Request Lighting Review
Reinstruction of Persons Involved
Review Personal Protective Equipment
Install Safety Guard / Device
Inform Dept. Supervision
Inform all Staff
Other
Explanation of Corrective Measures:
Deadline to complete Corrective Measure:
By Whom:
Date Completed:
Signature of Person Reporting Incident Supervisor Signature Dept. Head Signature
By checking this box you have confirmed this Injury Package is given to the employee (if applicable).
Indicate / ensure copies are distributed to: Dept. Head Union / Bargaining Group Local JHSC as appropriate
Description of Incident continued:
Continued on Attachment
Revised
September 2019
Incident Report Page 2
Reminder: For Health Care Injuries the Injury Package must be given to the employee.
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Purpose of the Incident Report Form
• To ensure compliance with Workplace Safety and Insurance Board and Occupational Health and Safety Act, which require
timely reporting of occupational injury or disease.
• Information requested on this form will be used by Occupational Health and Wellness (OHW) for the completion of the
required WSIB Form 7 and by the Environmental Health and Safety (EHS) to provide information to the Ministry of Labour, if
required.
• The form also ensures the area supervisor is aware of, and has followed-up on, the incident/injury and/or property damage
that has occurred.
Separate
and confidential forms are available for submitting details of violence and harassment. This form need only
be completed with minimum details: name of affected party, supervisor, location etc.
How to Fill
Out this Form - The form has been divided into two sections.
The top section is to be filled out by or for the injured person or the person involved in a hazardous situation. Students,
visitors, and volunteers may require assistance. If the injured party is unable to fill out this section, for whatever reason, it is to
be completed by the area or staff member’s supervisor or can be initiated by a co-worker if the supervisor is unavailable. The
lower section is to be completed by the direct supervisor of the employee or of the area generating the report.
Injured Pa
rty Section
• Ensure that all personal information is entered correctly and the details of the incident are documented as thoroughly as
possible. Every item in this section requires an answer. Please ensure the supervisory contact information is complete.
• If you require the use of an attachment, please indicate this by checking the “continued on Attachment” on the bottom of page
2.
• The form is to be signed by the injured party/ worker (if they are able) or by the person reporting the incident, prior to faxing
by the supervisor.
•
If you seek medical attention even after the incident report form has been submitted, please notify your supervisor
and OHW. Your supervisor will provide you with an Injury Package which includes a letter that explains the process, a
Functional Abilities Form (FAF), and a letter to your health care practitioner about our modified work program.
Supervis
or Section
• Contributing Factors: Check off one or more of the boxes that represent the causal factors of the incident being reported.
• For insurance reasons and/or to implement prevention strategies, ensure that any property damage is detailed in this section.
• Corrective Measures: Care must be taken to complete this important section. Indicate what steps were taken by the
supervisor/employer to mitigate the risk(s) associated with the task and/or prevent its reoccurrence. For whatever action was
taken or recommended, ensure that the details of the maintenance request/work order are outlined here. Also include the
name of outside providers, where appropriate. Document known facts only.
• Acquire signatures before submitting form, if possible, however, do not delay submitting the form if you cannot obtain
the signature of the injured party or the department head. This can be arranged later. Send the form into OHW so that
the respective WSIB and MOL notifications can be made.
• Ensure that the department head, respective union/bargaining group and Local JHSC, as applicable receive a copy
of this form. Indicate the distribution on this form.
•
If an employee has incurred a health care injury where professional medical attention is sought please provide them with the
Injury Package and check the box to confirm that you have done so. The Injury Package includes a letter explaining the
process, a WSIB Functional Abilities Form (FAF), and a letter for the health care practitioner. Please note that the Injury
Package should be provided at any time (even after an incident report is submitted) when an employee notifies you that he/
she will be seeking a medical professional related to a workplace incident.
•
The Injury Package can be found on the
OHW website
•
Advise the employee that modified work is available and to return
the completed FAF to OHW as soon as possible.
Revised September 2019 Incident Report Page 3
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University of Guelph - Illness or Injury Incident Report Form

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Completed 30 May 2020

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