Form IRSIR-FORAEN "Employee Incident Report - Public Services Health & Safety Association" - Ontario, Canada

Form IRSIR-FORAEN or the "Employee Incident Report - Public Services Health & Safety Association" is a form issued by the Ontario Ministry of Labor.

The form was last revised in August 1, 2010 and is available for digital filing. Download an up-to-date Form IRSIR-FORAEN in PDF-format down below or look it up on the Ontario Ministry of Labor Forms website.

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Download Form IRSIR-FORAEN "Employee Incident Report - Public Services Health & Safety Association" - Ontario, Canada

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Employee Incident Report
Incident
Public Services Health & Safety Association 4950 Yonge Street, Suite 902, Toronto ON M2N 6K1 416-250-2131 or 1-877-250-7444 www.pshsa.ca
Employee Incident Report
Incident
Public Services Health & Safety Association 4950 Yonge Street, Suite 902, Toronto ON M2N 6K1 416-250-2131 or 1-877-250-7444 www.pshsa.ca
Instructions for Completion
ORIGINAL to be kept in “Employee Incident
Report” file in H&S area/division
Employee Incident Report
2ND COPY to injured worker’s supervisor
The purpose of this report is to:
3RD COPY to injured worker’s occupational
health or employee file
•
Collect factual data relating to the occurrence of a workplace injury
•
Collect data for completion of the WSIB report
•
Provide a systematic means to record incidents, document the results of investigations and note how, when and what corrective
action will be taken
•
Help to ensure the provision of prompt medical treatment
•
Assist in the determination of the causative factors related to the incident
•
Systematically collect factual data for statistical records
•
Guide the investigator in conducting an e ective investigation
NOTE: Shaded information is considered confidential and should not be shared with the joint health and safety committee.
Types of Incidents - Definitions
Slip/Trip
The person either slips or trips but does not fall.
Struck/Caught
Overexertion
•
An incident in which a person has been struck abruptly or
An incident is one in which a person puts excessive strain on
forcefully by some object in motion (e.g., box falls o shelf,
some part of his/her body (e.g., an employee strains his/her back
employee jabs needle into finger, person pushing cart runs
or some other part of the body).
into someone) or a person is contacted non-forcefully by
some substance or agent in motion that has an injury-upon-
Harmful Substances/Environmental
contact characteristic (such as being splashed by hot or
An incident in which the employee is exposed to harmful
corrosive solutions).
condi¬tions (e.g., toxic gases, fumes or vapours; toxic airborne
•
An incident in which a person strikes abruptly or forcefully
particles; extremes of heat or cold; oxygen deficient atmospheres;
some stationary object in his/her surroundings (e.g., nurse
radioac¬tive radiation; intense light brightnesses, infectious
strikes his/her leg against the crank of a bed) or comes into
diseases, blood/blood-stained body fluids, moulds/spores).
contact, non-forcefully, with some stationary substance or
agent that has an injury-upon-contact characteristic (such as
Assault
electrical shock).
An incident in which the employee is subjected to an untoward
•
An incident in which a person is:
action by a patient or member of the public (e.g., a patient bites
a. trapped in some type of enclosure or a part of a person’s body
or strikes an employee).
is caught in some type of opening (e.g., a person is caught in
an elevator or locked into a refrigerated room)
Repetition
b. caught on some protruding object (e.g., a person’s clothing
An incident that develops over a period of time due to the
gets hooked onto a handle or a person catches his/her hand
repetitive nature of the task being carried out (e.g., pipetting,
on a sharp edge)
keyboarding).
c. pinched, crushed or otherwise caught between either a
moving object and a stationary object or between two or
Fire/Explosion
more moving objectives (e.g., a person jams his/her fingers
An incident in which the employee is subjected to a fire or
between a wheeled cart and doorway).
explosion in the workplace.
Fall
Motor Vehicle Incidents
A fall on the same level on which a person was standing or
An incident in which the employee is involved in a motor vehicle
walking, or when a person falls to below the level on which
incident during the course of his/her work activities.
he/she was standing or walking.
Direct Causes - Definitions
Basic Causes - Definitions
Physical/Environmental
Job Factors
Contributing conditions such as machinery/equipment,
Work procedures, purchasing, design, training, engineering
house¬keeping, physical agents, chemical agents, personal
controls, etc.
protective equipment, temperature (heat/cold), etc.
Personal Factors
Personal
Physical restrictions, lack of training, motivation, inadequate
Contributing actions such as unauthorized equipment use,
capability, etc.
improper body motion, working at unsafe speeds.
Ontario Safety Association for Community & Healthcare
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