Incident report form

Use this form to report medical incidents and injuries while using the Sedra Student Design Centre space. This form must be completed immediately after each incident, once adequate medical attention has been obtained. This form can also be filled out to keep track of near-misses: incidents where something could have gone wrong.

Follow-ups to this form will be conducted by the Manager, SSDC, who will work with the injured person to fill out a formal UW Incident Report Form and forward to the Safety Office. This form starts the process of completing a formal Incident Report Form.

This form should be filled out as completely as possible and as soon as possible after an incident, ideally on the same day as the incident.

Personal information
Information on the person who has been injured.
Sex
Status
Were you an emoployee at the time of the injury/accident?
Co-op students are considered employees, whether or not they are being paid.
Faculty/Department
Design team
Were you part of a design team and working on a team project when this incident happened?
Which design team were you a part of?
Incident
Type of incident
Potential loss if not corrected
Probability of accident occurring again if not corrected
Care received
Specify the type of care received, including the names and location of doctors and other care providers.
Family physician
Health Services
Chiropractor/physiotherapist
Walk-in/urgent care
Emergency room
Other care
Include names & locations of physicians and other care providers.
Incident details
Provide the building and room number. For injuries off-campus (e.g., at competition) provide as much detail as possible.
Identify the size, weight, and type of equipment or materials involved.
Specify left or right side.
Action taken by self/department to prevent recurrence
Incident investigations are conducted by the Manager or Director, SSDC. Identify actions you have completed. Director or Manager will take additional actions, as required.
Lost time
Is there lost time from work due to this injury/incident?
Scheduled hours for week of injury