Injury & Incident Report Form

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All injuries and incidents, including damage to property, regardless of severity, are to be reported by completing an Injury and Incident Report form (available in two formats) Please use the PDF version of the form if you have issues opening the Fillable PDF version.:

Injury and Incident Report Form (PDF)

Injury and Incident Report Form (FILLABLE PDF)

Note:  If the forms won't open in the browser, please right-click and save to your hard drive.

Responsibilities

Supervisors/Deans

Supervisors/Deans are responsible for:

  • Ensuring that the injured person receives first aid immediately, if required.
  • Arranging to have the individual transported to the hospital to receive medical attention, if required.
  • Securing the area to ensure that evidence is not disturbed if the victim suffered a critical injury or fatality.
  • Contacting the Human Resources Generalist - Health, Safety & Wellness immediately in the event of a critical injury or fatality.
  • Obtaining the name of any witnesses.
  • When requested, assisting the injured person complete SECTION A of the “Injury and Incident Report Form”.
  • Completing and signing SECTION B of the “Injury and Incident Report Form” as soon as they become aware of an occurrence.
  • Submitting the form (both SECTION A and SECTION B) to the Human Resources department within 24 hours of the occurrence*.
  • Following-up to ensure recommendations made during the investigation are implemented and adequate.

* The form may not be delayed for lack of information or signature(s).

The “Injury and Incident Report Form” must be completed and submitted to the Human Resources within 24 hours of first being notified of an injury. The WSIB levies a fee for late reporting of a lost time injury or health care claim. Where this late reporting is a result of the failure of a department to report the injury within the required timeline, the fine may be charged to that department.

It is strongly recommended that Supervisors/Deans name an alternate to complete this task in case of their unavailability.

Injured person or person reporting a near miss

Employees/students/visitors are responsible for:

  • Obtaining first-aid or health care (medical aid) in cases of injury and reporting such treatment to their Supervisor, Dean or host.
  • Reporting an injury/incident to their Supervisor, Dean or host immediately, or as soon as possible.
  • Co-operating with the completion of the “Injury and Incident Report Form” SECTION A, if available.
  • Co-operating during the investigation, if assistance is requested.