Quick Report

Today's Date*

Your Information

Your Name*

First Last

Your Email Address*

Enter Email Confirm Email

College Phone ext.

Other Contact Phone Number

Your Relationship to the College*

Faculty
Support Staff
Administration
Student
Contract / Public / Other

Your College Area*

President's Office
Academic Services
Student Services
Human Resources
Finance & Administration
Digital Technologies & Innovation
International & Strategic Planning
Communications, marketing & External Relations

Faculty / School / Department

Incident Information

Date of Incident*

Time of Incident*

:

Describe Incident Location

Nature of Accident / Incident*

Employee Automobile Accident / Injury
Employee Accident and / or Injury (Other than above)
Student Accident and / or Injury
Public / Contractor / Other Accident and / or Injury
Minor College or Personal Property Damage or Loss (less than $1000.00)
Incident involving a potential for College liability

Incident Description - Briefly describe what happened below*

For Property Damage or Loss - estimate total value ($)

Your Supervisor's Name (Chair if student)

Supervisor's Email Address (Chair, if student)

Enter Email Confirm Email

Supervisor's Phone ext.

Mechanism of Injury (if applicable)

Primary Injury Site (If Applicable)

Check all of the following statements that apply in the event of an accident / injury

I have discussed this incident with my supervisor (Coordinator or Chair, if student)
I have sought medical treatment through the College Health Services
I have sought health care services from another provider (ie. family physician, public clinic, hospital)
As a result of the incident, I will lose time from work (class, if student) beyond the day of the accident

Describe Automobile Ownership

Automobile owned by me and used for work purposes
Automobile rented by College
Automobile owned by College

Were there other automobiles involved?

Yes
No

Notes

If more than 1 additional person / vehicle were involved, please provide additional information in the narrative section below.

Name of other driver

First Last

Phone Number of other driver

Insurance Company and Policy Number of other driver

Make, Model, License plate of other vehicle

Were any other persons injured?

Yes
No

Did Police Attend the Accident?

Yes
No

If yes, enter police force and file number below:

Notes

Personal information on this form is collected in accordance with the Freedom of Information and Personal Privacy Act, R.S.O. 1990, c. F.31 (“FIPPA”), and under authority of the Ontario Colleges of Applied Arts and Technology Act, 2002, S.O. 2002, c. 8, Schedule F, and other relevant legislation and is collected for the purpose of administering the College’s Risk Management Program. Questions regarding collection of this information should be directed to the Program Coordinator.

Comments

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Risk Management

Quick Report

On-Line Quick Report

Your Information

Incident Information

Notes

Notes

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