Fillable Form 421-1-Employee Accident/violent Incident Report Form printable pdf download

FORM 421-1

Adopted

June 10, 2010

Last Revised

November 2014

Review Date

November 2015

Annual Review

EMPLOYEE ACCIDENT/VIOLENT INCIDENT REPORT



CHECK ONE

ACCIDENT

VIOLENT INCIDENT

INSTRUCTIONS:



Report the accident/violent incident immediately to your principal/supervisor



Print out this form and complete all sections and sign and date it



Ensure your principal/supervisor or designate signs the bottom of the form



SEND THE ACCIDENT/VIOLENT INCIDENT REPORT TO HUMAN RESOURCES SUPPORT SERVICES

IMMEDIATELY FOLLOWING THE ACCIDENT/VIOLENT INCIDENT (within 24 hours)

ATTENTION: HUMAN RESOURCES COORDINATOR AND HEALTH AND SAFETY OFFICER

FAX: 613-966-1397 OR EMAIL:

hr.services@hpedsb.on.ca

EMPLOYEE INFORMATION

EMPLOYEE NAME: ______________________________

HOME PHONE NUMBER: _________________

WORK LOCATION: ______________________________

DATE OF BIRTH:

_________________

ACCIDENT LOCATION: __________________________

JOB TITLE/POSITION: _________________

(classroom, hall, parking lot, etc.)

WORKING HOURS: FROM: _________ TO: _________

DAYS WORKED PER WEEK: _________________



ACCIDENT/VIOLENT INCIDENT DATES AND DETAILS Please

all that apply):

 AM PM

Date

Time

 AM PM

Date & Time Reported:

Date

Time

Reported to: (Name and Position)

______________________________________________________________



1. WAS ACCIDENT/VIOLENT INCIDENT (Please

all that apply):

 Sudden Specific Event/Occurrence

 Gradually Occurring Over Time

 Occupational Disease

 Verbal (i.e., threat)

 Physical



2. TYPE OF ACCIDENT/VIOLENT INCIDENT (Please

all that apply):

 Struck/Caught

 Fall

 Slip/Trip

 Overexertion

 Harmful Substance/Environment

 Motor Vehicle Accident

 Repetition

 Assault

 Fire/Explosion

 Other _______________________________________



3. AREA OF INJURY (BODY PART) (Please

all that apply):

Head  Face  Eye(s)  Ear(s)  Teeth  Neck  Chest  Upper Back  Lower Back  Abdomen

 Pelvis  Other ____________________________________

IF INJURY OCCURRED, CONTINUE WITH SECTION 4, IF NO INJURY HAS OCCURRED GO TO SECTION 5.



4. PLEASE INDICATE LOCATION OF INJURY AND LEFT OR RIGHT:

L  R 

Shoulder

Arm

Elbow

L  R 

Forearm

Wrist

Hand

L  R 

Finger (s)

Hip

Thigh

L  R 

Knee

Lower Leg

Ankle

L  R 

Foot

Toe (s)

5. DESCRIBE: what happened to cause accident/violent incident and what you were doing at the time.

For accidents: provide details related to equipment or conditions that may have been involved.

For violent incidents: describe the nature of the incident (physical/verbal/weapons/etc.) and the context.

(if additional space is required please use a blank sheet and submit with this document)(additional sheet attached  Yes)

LOCATION: On Employer’s premises  Yes

 No

__________________

Specify where (classroom, hall, parking lot, gym, etc.)

REPORT ANY WITNESSES: __________________________________

___________________________________

Form 421-1-Employee Accident/violent Incident Report Form

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