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Directory
First Name
*
Last Name
*
Email Address
*
Phone
Incident Type
Select:
New
Health and Safety Reporting
Incident Location
Select:
3 Old York Campus
314 Airport Road - Admin Building
314 Airport Road - AMO
314 Airport Road - Greenhouse
314 Airport Road - ILC
Other Location
Date of Incident
Time of Incident (HH:MM AM/PM)
8
Characters Remaining
Date Reported
Time of Report (HH:MM AM/PM)
8
Characters Remaining
Summary of Incident
Reported to Supervisor/Instructor
Yes
No
Student/Employee Number
Department/Program
Injury Area
Select:
Abdomen
Ankle
Arm
Back
Chest
Face
Finger
Foot
Hand
Hip
Knee
Leg
Multiple
Neck
Shoulder
Toe
Wrist
Other
N/A
Injury Type
Select:
Abrasion
Burn
Contusion/Bruising
Eye Injury
Fracture
Laceration/Cut
Medical
Multiple Injuries
Puncture
Strain/Sprain
Other
N/A
Injury Mechanism
Select:
Assault/Violence
Awkward Posture/Motion
Caught on/in
Contact with sharp object
Contact with Substance
Fall
Medical Condition
Motor Vehicle
Motorcycle
Training
Needlestick
Recreation/Fitness Activity
Slip/Trip
Struck by/against
Other
N/A
Was Medical Sought
Yes
No
Date Medical Sought
Name/Address of Medical
If Incident occurred on placement-Name of Placement
Corrective Action
Select:
Equipment Repair
Housekeeping
Maintanece
Procedure Development
Other
N/A
Corrective Action Completed
Root Cause
Select:
Actions of another person
Defective/Missing Equipment
Failure to Correct Hazard
Failure to Follow Work Instruction/Program/SOP
Failure to Use PPE
Hurry/Haste
Improper Use of Tools/Equipment/Material
Lack of Training
Poor Housekeeping
Other
N/A
Add Person (optional)
Involvement Type
Select:
Contractor
Employee
Student
Visitor
Other
Name
Email
Student/Employee Number
Involvement Type
Select:
Contractor
Employee
Student
Visitor
Other
Name
Email
Student/Employee Number
Involvement Type
Select:
Contractor
Employee
Student
Visitor
Other
Email
Name
Student/Employee Number
