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
• 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.
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.
• 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
• 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.
• 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
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