Injury Occurrence Report Webform - New

This webform should be completed by a supervisor (employee), program representative (student) or Confederation College contact (3rd party vendor/contractor) after an injury incident has occurred.

Community members should contact Public Safety at [email protected].

If you require immediate and urgent assistance:

  • Call 922 from a College phone, or 623-0465 when on the Thunder Bay campus and provide the following information, when prompted by the Security Guard:
    • Your name, current location, and current phone number,
    • The location and description of the emergency,
    • The nature of any injuries, and
    • The types of service required (ie. Security, Campus Response, Police, or Ambulance).
Report Details (Required)
What type of occurrence was this? (Select all applicable categories.)

This is a description of the location of the occurrence, including building & room number. If the occurrence happened outdoors, give references to buildings, parking lots, roads, towns, etc)
 

This is the date that the occurrence happened, or the date that the injured person became aware of the disablement or illness.
This is the date that the occurrence was reported to a supervisor, or a person in authority.
Critical injuries and fatalities must be reported immediately. All other injuries must be reported within 24 hours. If there was a delay in reporting, provide reasons for the delay.
The occurrence report is completed by the supervisor of the injured party, or their designate; or by a person with authority to complete the report (i.e. any manager in Human Resources Services; Public Safety staff; Health Services staff; a regional campus manager, or the manager of the Fitness Centre, Children & Family Centre or Sibley Hall Residence).
Student Supervisor/Faculty Details
Provide the name of the faculty member. If unknown, enter "unknown".
Provide the name of the faculty member. If unknown, enter "unknown".
Identification of Injured Party (Required)
What is the age range of the injured party?
Is the injured party a member of a union?
Address (Required)
This is the injured party's local address (street name & number, rural route, apartment number).
This is the injured party's city or town.
This is the injured party's province.
This is the injured party's postal code.
Injury, First Aid and Health Care Details (Required)
Was the accident or illness:
Describe the injury or disablement, specifying part of body affected, and right or left side. Example #1: 1 cm cut to the palm of left hand below index finger. Example #2: hearing loss in left ear.
First Aid (Required)
Was first aid provided?
Was first aid provided, including self-treatment by the injured party?
Who provided first aid?
Who provided the first aid?
If first aid was provided, describe the treatment (including any self-treatment). For example: elevated and iced ankle; cleaned and dressed wound; etc.
Health Care (Required)
Did the injured party receive health care for this injury?
Health care includes the services of a doctor, chiropractor, physiotherapist and dentist.
Where did the injured party receive health care?
This describes where the injured party received health care.
How was the injured party transported to health care?
Has the injured party been referred for additional health care beyond the initial treatment?
Health care includes the services of a doctor, chiropractor, physiotherapist and dentist.
Occurrence Details (Required)
What was the immediate cause of the occurrence (select all that apply)?
Example #1: The employee stepped on some spilled coffee; their left foot slipped and they fell forward, landing on their right knee, and extended their right arm to break the fall. Example #2: The student was on a ladder, about 8 feet off the floor. They were coming down the ladder with their back to it; carrying a camera in their right hand; and using their left hand for support. Their left heel caught on a ladder rung, causing them to fall to the floor on their left side, fracturing their left collar bone.
Were there any equipment and/or material(s) involved in this accident?
Accommodations / Lost Time (Required)
Does the injured party have precautions, limitations or restrictions that must be followed?
Time Unit
On what is this estimate based?
Will the injured party be absent from work, school or placement beyond the day of the injury?
Time Unit
On what is this estimate based?
What were the injured party’s normally scheduled working (school or placement) days (select all that apply)
Were there any witnesses to / are there persons having knowledge of the incident
Witnesses / Persons Having Knowledge of Injury (Required)
Party #1
Party #1 is a
Party #2 is a
Party #3 is a
Confirmation of Information (For Print Use Only)
Injured Party
Person Taking Report