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INSTRUCTIONS:

Building Name/Room Number: Additional Location Details:

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Referenced from: Emergency Procedures & Lockdown

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INSTRUCTIONS:

  • This report must be reviewed and signed by the Supervisor, Manager, or Dean of the Faculty/Department.

  • •

  • The completed report must be submitted within 24hrs to Risk and Safety Department, email incidentreports@northern.on.ca

  • In case of a critical injury, immediately notify Risk Manager ext. 2153 or H&S Coordinator ext. 7006. Risk and Safety Department is responsible for communications to the Ministry of Labour, Training, and Skills Development (MLTSD).

1.0 PERSONAL DETAILS

Individual involved is:

  • ☐ Employee

  • ☐ Placement Student

  • ☐ Student

  • ☐ Contractor

  • ☐ Visitor

  • ☐ Not Applicable

First Name:

Employee / Student Number:

Last Name:

Job Title / Student Program:

Phone Number:

Email Address:

Faculty/ Department:

Supervisor/Instructor Name:

2.0 INCIDENT DETAILS

Where did the incident occur?

  • ☐ Timmins Campus

  • ☐ Haileybury Campus

  • ☐ KL Campus

  • ☐ Moosonee Campus ☐

Other:

Building Name/Room Number: Additional Location Details:

Date and Hour of Incident / Awareness of Illness:

Date (DD/MMM/YY): Time:

  • ☐ AM

  • ☐ PM

The incident/illness was reported to:

Name:

Position:

Phone:

Date and Hour Reported:

Date (DD/MMM/YY): Time:

  • ☐ AM

  • ☐ PM

Were there any witnesses or other persons involved in this incident/illness?

  • ☐ Yes

  • ☐

No

If Yes, provide names, positions, and work phone number(s) for each witness/person:

Incident Category (definitions on page 3):

  • ☐ Near Miss

  • ☐ Report Only

  • ☐ Property Damage

  • ☐ First Aid

  • ☐ Health Care

  • ☐ Lost Time

  • ☐ Occupational Illness

  • ☐ Critical Injury

Incident Type:

  • ☐ Struck By/With

  • ☐ Environmental

  • ☐ Fall Same Level

  • ☐ Fall Different Level

  • ☐

  • Slip/Trip ☐ Workplace Harassment

  • ☐ Overexertion

  • ☐ Repetition

  • ☐ Chem./Hazardous Material Exposure

  • ☐ Contact With/Between

  • ☐ Fire/Explosion

  • ☐ Motor Vehicle Accident

  • ☐ Workplace Violence

  • ☐ Previous Medical Condition

  • ☐ Other:

Nature of Injury:

  • ☐ Amputation

  • ☐ Bite

  • ☐

Bruise Consciousness

  • ☐ Burn

☐

Laceration/Cut

  • ☐ Illness

  • ☐ Foreign Body

  • ☐ Other:

  • ☐ Fracture

  • ☐ Loss of

  • ☐ Soreness/Pain

  • ☐ Sprain/Strain

  • ☐ Psychological

  • ☐ Puncture

Check all injured body parts: Circle affected areas:

  • ☐ Head

  • ☐ Teeth

  • ☐ Upper Back

  • ☐ Face

  • ☐ Neck

  • ☐ Lower Back

  • ☐ Eye(s)

  • ☐ Chest

  • ☐ Abdomen

  • ☐ Ear(s)

  • ☐ Pelvis

  • ☐ Other:

Left

Right

  • ☐

  • Shoulder ☐

  • ☐ Arm

☐

  • ☐ Elbow

☐

  • ☐ Forearm

☐

  • ☐ Wrist

☐

  • ☐ Hand

☐

  • ☐ Finger(s)

☐

Left

Right

☐

Hip

☐

☐

  • Thigh ☐

☐

Knee

☐

  • ☐

  • Lower Leg ☐

  • ☐ Ankle

☐

☐

Foot

☐

  • ☐ Toe(s)

☐

HEALTH & SAFETY INCIDENT REPORT

Incident Report | Northern College

Description of how incident/illness occurred (include people, equipment, environment, materials, and/or processes involved):

Describe any property damage (if applicable):

Was anyone not in the College’s employ totally or partially responsible for the incident:

  • ☐ Yes

  • ☐ No

3.0 TREATMENT OF INJURY

Did the individual receive first aid or medical aid?

  • ☐ Yes

  • ☐ No

If Yes, check provider:

  • ☐ East End Clinic

  • ☐ Security

  • ☐ Ambulance

  • ☐ Hospital

  • ☐ Health Professional Office

  • ☐ Walk-In Clinic

  • ☐ Other:

If Yes, provide date health care was

provided (DD/MMM/YY):

4.0 INVESTIGATION

Description of potential causes based on your investigation:

  • ☐ Unsafe equipment

  • ☐ Poor housekeeping

  • ☐ High/low temperature exposure

  • ☐ Inadequate illumination

  • ☐ Hazardous environmental condition

  • ☐ Excessive noise levels

  • ☐ Unsafe work practice

  • ☐ Failure to use PPE

  • ☐ Improper lifting technique

  • ☐ Other:

Description of corrective measures (if a Track-It was submitted, include the Work Order #):

  • ☐ Equipment repair/replacement

  • ☐ Install safety device

  • ☐ Check with manufacturer

  • ☐ Improve work procedure

  • ☐ On the job training

  • ☐ Perform housekeeping

  • ☐ Review PPE

  • ☐ Inform all staff

  • ☐ Other:

5.0 RETURN TO WORK (FOR EMPLOYEES)

After the day of the incident or awareness of the illness, this employee:

  • ☐ Returned to regular job duties and has not lost any time and/or earnings

  • ☐ Returned to *modified work and has not lost any time and/or earnings

  • ☐ Has **lost time and earnings

  • Provide the date employee first lost time: (DD/MMM/YY):

Report Completed by Name (please print): Signature: Date (DD/MMM/YY):

Supervisor or Manager Name (please print): Signature: Date (DD/MMM/YY):

*Modified work indicates a change to the regular work schedule, or an inability to perform the core functions of the job due to the injury and/or illness.

**Lost time is absence from the next scheduled shift. Fill in shift information below.

Supervisor/Manager to submit the completed form to Risk and Safety Department, email incidentreports@northern.on.ca within 24 hours of the incident. A copy of the form must be sent to the Supervisor, Manager, and/or Dean of the Faculty/Department.

PRIVATE AND CONFIDENTIAL: THE INFORMATION CONTAINED ON THIS FORM IS COLLECTED, USED AND/OR DISCLOSED PURSUANT TO THE FREEDOM OF INFORMATION AND PROTECTION ACT, 1990; THE PERSONAL HEALTH INFORMATION PROTECTION ACT, 2004; AND/OR THE OCCUPATIONAL HEALTH AND SAFETY ACT, 1990.

I NSTRUCTIONS & DEFINITIONS

ALL INJURIES WHICH OCCUR ON NORTHERN PROPERTY, OR OCCUR DURING WORK-RELATED OFF CAMPUS ACTIVITIES, MUST BE REPORTED TO YOUR SUPERVISOR AND OCCUPATIONAL HEALTH AND SAFETY.

  • When an employee sustains a work-related injury or illness, they must inform their Supervisor/Manager as soon as possible.
  • Once advised of an injury or illness, Supervisors/Managers are to ensure this Health and Safety Incident Report is completed and submitted to Risk and Safety Department within 24 hours emailed to incidentreports@northern.on.ca.).
  • Risk and Safety Department will, where required, report the injury or illness to other required external parties, including the Workplace Safety and Insurance Board (WSIB) and the Ministry of Labour, Training and Skills Development (MLTSD).

Individual/Employee’s Responsibilities:

  • call 911 if needed and contact Security if on-campus emergency response is required
  • obtain first aid as needed from Security
  • report all incidents, including injuries, occupational illnesses, near misses, and workplace hazards to their supervisor
  • participate in accident investigations upon request
  • provide information related to an injury, as required by WSIB, MLTSD, etc. to the Risk and Safety Department
  • maintain contact with the Risk and Safety Department and their supervisor through the recovery period and cooperate with the returnto-work process
  • an employee who has been exposed to a harmful chemical or substance that may result in illness or disease in the future may choose to complete the WSIB Worker’s Exposure Incident Form after completing this Health & Safety Incident Report.

Definitions:

Critical Injury

First Aid Injury

Health Care Injury

Lost Time Injury

Near Miss Incident A critical injury, as defined by Ontario Regulation 834 under the Occupational Health and Safety Act, is:

‘an injury of a serious nature that,

  • a. places life in jeopardy;
  • b. produces unconsciousness;
  • c. results in substantial loss of blood;
  • d. involves the fracture of a leg or arm but not a finger or toe;
  • e. involves the amputation of a leg, arm, hand or foot but not a finger or toe;
  • f. consists of burns to a major portion of the body; or
  • g. causes the loss of sight in an eye.’

The one-time treatment or care and any follow-up visit(s) for observation purposes only. First aid includes, but it not limited to: cleaning minor cuts, treating a minor burn, applying bandages and/or dressings, applying a cold pack, applying a splint.

Work-related injury requiring the professional services of a health care practitioner (e.g. doctor, chiropractor, physiotherapist) with no time lost from work beyond the day of injury.

Work-related injury causing a loss of time from work beyond the day of the injury; must be treated by a health care practitioner (e.g. doctor, chiropractor, physiotherapist).

An occurrence that does not result in injury/illness or property damage but which, under slightly different circumstances, could have resulted in harm to people, damage to property or loss to process.

Occupational Illness A condition that results from exposure in a workplace to a physical, chemical or biological agent to the extent that the health of the worker is impaired.

A minor injury or event that requires no treatment

Report Only

Supervisor/Manager Responsibilities:

  • contact 911 if needed and contact Security if on-campus emergency response is required
  • ensure first aid/medical response is provided
  • report and investigate all injuries, illnesses and near miss incidents
  • submit the completed Health & Safety Incident Report to the Risk and Safety Department within 24 hours of being notifying
  • immediately notify the Risk and Safety Department of all fatal / critical injuries
  • preserve the scene of a fatal or critical injury until a MLTSD inspector advises otherwise
  • develop and implement corrective measures based on findings of investigation(s)
  • monitor corrective measures to determine effectiveness

In the event of a Critical Injury or Fatality:

  • a. The first person on the scene shall report the injury to
  • Security, ext. 6842, and
  • 911 at off-campus locations

Security and the supervisor/manager or instructor responsible for the area shall secure the incident scene - no person shall disturb the area until permission has been given by a MLTSD inspector (unless necessary to prevent further injury).

  • b. Security and the supervisor/manager or instructor responsible for the area shall immediately report the incident to OHS (ext. 2153 or 7006). After hours, Security shall notify the Risk Manager.
  • c. The supervisor/manager or instructor responsible for the area shall notify their Faculty or Department head (Dean, Associate Dean, and Director) of the incident.
  • d. The Faculty/Department head, or designate, shall notify the injured person’s immediate family or other persons as directed by the individual. Where required, the Faculty/Department Head or designate may request the assistance of the Risk Manager, police officer, clergy person, employee’s supervisor, counselor, union representative or other.
  • e. Risk and Safety Department will immediately notify the MLTSD, the Joint Occupational Health and Safety Committee and, if the injured person is represented by a union, the appropriate OPSEU Local President or alternate. The Communications Manager will also be apprised of the situation. If after hours, the Risk and Safety Department will notify the MLTSD.
  • f. Risk and Safety Department, in cooperation with the supervisor/manager for the area, shall coordinate the accident investigation process.
  • g. Risk and Safety Department shall submit a written Notification of Accident report, detailing the prescribed information, to the MLTSD within 48 hours of the accident.

All media inquiries are to be directed to the Communications Manager, Marketing and Communications. Under no circumstances should any member of Northern College, unless authorized to do so, make any statements to the media.

Source: https://www.northerncollege.ca/uploads/2025/07/HSE-Incident-Report-Form.pdf