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St. John's, Marine Institute, Labrador Campus, Harlow Campus - Report an Accident (person/property)

GUIDELINES

Report an Accident (Injury, Illness and/or Property Damage)

This form has been created to allow all members of the University community to report an Accident (an incident which has given rise to injury, illness, fatality or property damage). The report will be assigned to the proper resource within the University for follow-up.

Please Note:

While this resource is available for reporting 24 hours a day, 7 days a week; the system is not be monitored 24 hours a day. If the incident is an emergency that requires immediate action please contact Campus Enforcement and Patrol at 709-864-4100 or 911 (St. John's Campus), or emergency services/maintenance personnel at your location.

System will timeout after 30 Minutes. Please complete report within that time.

General Information *

Time Reported

:

*

Creator Email

I want to receive a copy of this E-Alert in my e-mail

Location (St. John's Campus) *

Location *

My Location is Not Listed:

Location Not Listed (On Campus)

Affiliation of the Reporting/Affected Person? *

Employee (Faculty/Staff)	Student
External (Contractor/Visitor/Guest/No Affiliation)	Unknown

Is this a laboratory?

Yes

No

MUN Safe Location (Admin Use Only)

* Required Fields.

General Information

Name of Injured/Involved Person

Email

Invalid email address. Example: smith@sample.com

Phone Number

Role at the Time of the Incident

If Other, Please Specify

Name of Supervisor

Supervisor Phone

Supervisor Email

Invalid email address. Example: smith@sample.com

Date and Time of the Incident

Are there any witnesses to this incident?

Yes

No

Witness Name

Witness Phone Number

Witness Email

Invalid email address. Example: smith@sample.com

Any additional witness information can be written into the details section of this report.

Incident Details / Narrative

Accident Details *

Accident: Is an incident which has given rise to injury, illness, fatality, or property damage.

Accident Information

Type of Accident *

Accident Details

Type of Hazard *

Safety: Driving, Electrical, Fire/Explosion, Forklifts, Ladders, Machinery, Material Handling, Platforms, Slips trips and falls, Tools, Leaks, Equipment malfunctions or breakdowns

Health: Biological (bacteria, mould, viruses, insects, plants, birds, animals, and humans), Diseases/disorders/injuries, Pandemics

Chemical: the physical, chemical and toxic properties of the chemical; includes asbestos, odours

Ergonomic: Lifting/pushing/pulling, Sitting/standing, Musculoskeletal Disorders, Lighting, Shiftwork, Office, Tools

Physical: Temperature, Indoor Air Quality, Noise, Radiation

Psychosocial: Stress, Violence/bullying, Mental Health

Type of Event

Please indicate the conditions in the area at the time of the incident:

If other, please describe:

Injury Information

Illness Information

Injury/Illness Category *

Was first aid provided at the scene of the accident?

Yes

No

Name of first aid provider on the scene (if applicable):

Description of first aid treatment given:

Date of medical treatment (if applicable)?

Was the victim transported to hospital?

Yes

No

Name of Facility:

Address of Facility:

At the time of the incident, was the injured/ill person working as a paid employee of Memorial University? *

Yes	Unknown/Not reported
No

Please identify the Human Resources Unit the injured person would report to: *

Human Resources Memorial University	Human Resources Marine Institute
Human Resources School of Medicine	Human Resources Grenfell Campus

Has the employee been provided with a Workplace NL Worker's Report Of Injury Form (Form 6)?

Yes	Not applicable - not an employee
No

Please download a Worker's Report of Injury Form (Form 6). This form can be accessed though the forms section of the Workplace NL website at workplacenl.ca. The worker should return the form to Workplace NL as soon as possible.

Has a Workplace NL Employer's Report of Injury Form (Form 7) been filled out?

Yes	Not applicable - not an employee
No

Please download an Employer's Report of Injury (Form 7). This form can be accessed though the forms section of the Workplace NL website at workplacenl.ca. The employer should return the form to Workplace NL as soon as possible.

Was there lost time associated with this incident?

Yes	N/A
No

Potential Injury Type

Type of Injury

Type of Illness

Exposure

Open Wound / Laceration

If Other, Please Specify

If Other Illness Type, Please Specify

Area of Body

Arm(s)

Left Side

Right Side

Ear(s)

Left Side

Right Side

Eye(s)

Left Side

Right Side

Foot/ Ankle(s) / Toe(s)

Left Side

Right Side

Hand(s)/Wrist(s)/Finger(s)

Left Side

Right Side

Knee

Left Side

Right Side

Leg

Left Side

Right Side

Shoulder(s)

Left Side

Right Side

If Other, Please Specify

If Multiple Body Parts, please specify:

Additional Information

If other please describe:

Infrastructure/Property Damage Information

Incident Type

Add Damage Details

Property Type

Other property, please specify

Description of Damage

Cause of Damage

Cause of Building Closure

Other, please specify

Cause of Power/Equipment/Systems Failure

Weather Event Type

Other, please specify

Owner of Property

Other, please specify

Value of Damage (if known)

Sum up this amount to the Total.
Invalid currency value

Total Value of Damage
Total:

Is the outage isolated to a particular area?

Yes

No

Please list areas affected:

Will these damages have to be reported to a University Insurance Provider?

Yes	Unknown
No

Please complete Investigation section if applicable. Also enter a brief description of events in the Narrative section for this report. Please try to include all pertinent details of the incident, but be as concise as possible.

Investigation Details

Investigation Details - Causes

Immediate Causes

Substandard Acts

Substandard Conditions

Substandard Acts

Substandard Conditions

Basic (Root) Causes

Personal Factors

Job Factors

Personal Factors

Inadequate Physical/Physiological Capability	Mental or Psychological Stress
Inadequate Mental/Psychological Capability	Lack of Competence
Physical or Physiological Stress	Improper Motivation

Inadequate Physical/Physiological Capability

Inadequate Mental/Psychological Capability

Physical or Physiological Stress

Mental or Psychological Stress

Lack of Competence

Improper Motivation

Job Factors

Unclear Organizational Structure

Inadequate Leadership

Inadequate Supervision/Coaching

Inadequate Management of Change

Inadequate Supply Chain Management

Inadequate Maintenance/Inspection

Excessive Wear/Tear

Inadequate Tool/Equipment/Machinery/Device

Inadequate Product/Service Design

Inadequate Work/Production Standards

Inadequate Communication/Information

Corrective / Preventative Actions

Has corrective action been implemented?

No

Yes

Control Type(s)

Elimination - Physically remove the hazard	Administrative Control - Change the way people work
Substitution - Replace the hazard	PPE - Protect the Worker with PPE
Engineering Control - Isolate people from hazard

Please describe any corrective or preventative measures that have been or will be implemented to prevent reoccurrence of the incident.

Recommendations

Attachment

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Attached Files

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* Required Fields.