Online Workplace Accident/Incident Report for Employees
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University of Toronto
Workplace Accident/Incident Report Form

This form should be  completed and submitted by an employee's supervisor /manager in the event of an incident or injury. Where an employee has been injured, the supervisor of the employee must submit this form within 24 hours of the incident. Failure to report injuries which result in health care or lost time from work (other than the day of injury) may result in a financial penalty to the applicable department.

This form may also be used to report incidents like near misses, where there was no injury, but the potential for injury existed.

Important Note:

This online form has a time limit of 20 minutes per page.
Please ensure that you have all of the details of the incident and the personal information of the employee involved before you start to complete the form.
If the session has expired, please go back to the instructions page and click on the "e-form for employees" link. You will have to reenter the data into the form.
Once submitted, a copy of this report will be sent to the e-mail addresses that you provide on this form.

If you may need further clarification/s, please refer to the sample webform or the list of  definitions/additional information and instructions .

Page 1 of 4
A. INCIDENT REPORTING INFORMATION
Classification:
Critical - broken limb, substantial loss of blood, unconsciousness, amputation, loss of sight, burns to major part of bodyAssistance from U of T staff (first aid)
Lost time or earningsAssistance from healthcare practitioner
No physical injuryOccupational exposure to harmful substance eg. asbestos, lead, mercury
Health effect from workplace exposure - e.g. occupational dermatitisMinor - no treatment
Name of person completing report
B. EMPLOYEE INFORMATION
1. Injured person's last name:
2. Injured person's first Name:
3. Sex:
Male
Female
3a. Dominant hand:
Left
Right
4. Employing Department Name of injured - select from applicable campus drop-down list.
St. George
UTSC
UTM
Department and campus if unable to locate above:
5. Personnel number of injured:
6. Job Title of injured party:
7. In current position less than six(6) months?
8. Employee Group:
8a. If you have selected "Other" under Employee Group, please specify:
9. Appointment type:
10. Union:
11. Injured person's E-Mail Address (to receive copy of form):
 
12. Injured person's home address:
13. Home or cell phone number:
 
14. Work Phone Number:
 
15. E-Mail Address of supervisor/manager (will receive copy of form):
 
16. Email address of Department Chair, Director, or Manager (will receive copy):
 
 

The University of Toronto respects your privacy and is committed to protecting confidentiality through the application of sound and secure practices. The University will protect all personal information in accordance with applicable privacy legislation. Personal information that you provide to the University is collected pursuant to section 2(14) of the University of Toronto Act, 1971 and may be used and disclosed for purposes that the University considers necessary for sound human resources administration and related activities, including, for example, those relating to recruitment, selection and hiring and payroll and benefits administration. If you have questions, please refer to www.utoronto.ca/privacy or contact the University Freedom of Information and Protection of Privacy Coordinator at 416-946-7303, McMurrich Building, room 104, 12 Queen's Park Crescent West, Toronto, ON, M5S 1A8.

If for some reasons some information is not available to you, please submit what you have and submit further information as soon as you have it.
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