Create CAIR

Campus Accident / Incident Report

Report all Campus Accidents/Incidents and Near Misses within 24 hours

The Alberta Occupational Health and Safety Code (Section 182) requires that all illnesses and injuries that occur at a worksite MUST be reported.

Emergency assistance (24/7): Campus Security (403) 329-2345
General enquiries: Campus Safety (403) 329-2603

Instructions:

  1. Employees must immediately report all incidents/accidents and near misses to their Supervisor.
    (Note: Students must immediately inform their class instructor/professor.)

  2. Supervisors must complete an Incident Investigation Report (IIR) form in consultation with the employee/student and submit it to safety.services@uleth.ca  

This serves to identify corrective measures that may prevent recurrence.


For personal security concerns please proceed to the following link:
http://www.uleth.ca/policy/harassment-and-discrimination-policy
Or Call (403) 329-2274

Demographics

Demographics
Format: (XXX)-XXX-XXXX
Format: (XXX)-XXX-XXXX
Format: LNL NLN

Details of Accident/Incident/Near Miss

Details of Accident/Incident/Near Miss
 Tue, 2018-01-16 20:28
Format: 2018 Jan 16
Format: 08:28PM
Please indicate name of department/supervisor/instructor
Please also include witness contact information
A Near Miss means any undesired event or incident that under slightly different circumstances could have resulted in personal injury, illness, environmental release, or loss.

Critical Impact Details

Critical Impact Details

Injury/Illness Details

Injury/Illness Details
* If medical Aid is required, please follow up with the Wellness Coordinator at 403-332-5217,
within the next 24 hours.

WCB Reporting: - any work related injury or illness that results in the following must be reported to WCB within 72 hours:
  • lost time – or probable lost time - beyond the day of accident
  • the need for medical treatment beyond first aid (i.e. assessment by physician, physiotherapist, chiropractor)
  • a temporary or permanent change in your ability to perform the regular duties of your job
  • incurring medical aid expenses (i.e. dental treatment, eyeglass repair/replacement, prescription medications)
If your injury/illness meets the criteria above , you must contact Wellness & Recognition at 403-332-5217 (suzanne.mcintosh@uleth.ca or susan.roth@uleth.ca) as soon as possible to ensure you receive appropriate and timely medical treatment.
Categories of the Injury/Illness (Please select 1 from each category)

Property Damage Details

Property Damage Details
* If not property, please indicate other and put N/A in description Box.
* Complete Details Required

Preventative Measures

Preventative Measures

Other/Emergency Contact

Other/Emergency Contact
Format: (XXX)-XXX-XXXX
Section 184(3) of the Alta. OH&S Code states a copy of this report is to be provided to the worker. By printing copy of this report for your records the University has complied with this requirement under the Code.
The Personal information gathered in this form is protected by the Alberta Freedom of Information and Protection of Privacy Act (FOIPP) and the Health Information Act (HIA). The dissemination of any of the information contained herein is subject to the provisions of FOIPP and HIA.