Integrated Risk Management
Ryerson University Internal Report
Accidents – Incidents – Exposures
SECTION A: Information About the Event
Type of Event:
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Does Not Apply
Unknown
Exposure to Hazardous Materials
Injury with Property Damage
Injury with Release of Hazardous Materials
No Injury with Property Damage
No Injury with Release of Hazardous Materials
Occupational Illness
Serious Near Miss
Other (Describe):
Tripping event resulting in a fall and injury. Location was LG JOR hallway just outside the One Card
Office in an area designated for pedestrian movement.
Number of Persons Involved:
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Does Not Apply
Unknown
One Person
Multiple People – Requires Information on EACH person
Other (Describe):
Date of Event:
Time of Event:
AM☐|PM☐
Date Reported to Supervisor:
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Time Reported to Supervisor:
AM☐|PM☐
Where did the Event Occur?
On Campus
If INSIDE, On Campus:
Hallway
BUILDING:
JOR
ROOM:
Close to ROOM:
If OUTSIDE, On Campus:
Choose an item.
Other (Describe):
The Event/Illness was:
Other (Describe):
Other (Describe)
The SOURCE of Injury/Illness:
Other (Describe):
Floor
IF PROPERTY WAS DAMAGED:
☐ Pictures Attached to Report
In point form, provide the following information about the item(s) damaged and WHY/HOW the
property was damaged in the box below:
1) Type of machine, equipment, tool, etc.
2) Type of damage that occurred
3) How the damage occurred
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NOTES:
SECTION B: Information About Injured Person or Person Involved with Event
☐ Does NOT Apply
☐ Unknown
Last Name:
Middle Initial:
First Name:
RU Email:
Job Title:
Department:
Started Current Position:
Number of Years in Position:
Joined Ryerson?
Number of Years at Ryerson:
Status at Time of Event:
Employee (Full Time)
Association:
RFA
Was Treatment Required?
☐NO – Continue To Next Question
☐YES: Escorted to Ryerson Medical Centre
OTHER (Describe):
Was Time Lost?
☐NO – Continue To Next Question
☐YES
OTHER (Describe):
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Personal Information:
SEX: Female
AGE:
☐ Does NOT Apply | ☐ No Witness(es) | ☐ Unknown Witness(es)
Witness 1:
Phone #
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Employee
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Other
Witness 3:
Phone #
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Employee
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Other
Witness 5:
Phone #
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Employee
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Other
SECTION D: Type of Contact
Type of Contact:
Other (Explain):
Fall on Same Level
IF THIS WAS A SLIP, TRIP, or FALL REVIEW THE FOLLOWING:
Surface Description:
Floor Covering:
Dry
Does NOT Apply
Distractions:
Stair Conditions:
Does NOT Apply
Does NOT Apply
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Foot Ware Type:
Lighting Conditions:
Sandals
Adequate
Railings:
Eye Glasses:
Does NOT Apply
Unknown
NOTES:
SECTION E: Part(s) of Body Injured
☐ DOES NOT APPLY
☐ Head
☐ Face
☐ Teeth
☐ Neck
☐ Chest
☐ Pelvis
☐ Abdomen
☒ Upper Back
☒ Lower Back
LEFT SIDE
☐ Ear
☐ Shoulder
☐ Upper Arm
☐ Elbow
☐ Lower Arm
☐ Wrist
☐ Hand
☐ Fingers(s)
☐ Eye
☐ Hip
☐ Upper Leg
☐ Knee
☐ Lower Leg
☐ Ankle
☐ Foot
☐ Toe(s)
RIGHT SIDE
☐ Ear
☐ Shoulder
☐ Upper Arm
☐ Elbow
☐ Lower Arm
☐ Wrist
☐ Hand
☐ Fingers(s)
☐ Eye
☐ Hip
☐ Upper Leg
☐ Knee
☐ Lower Leg
☐ Ankle
☐ Foot
☐ Toe(s)
Other (Describe):
SECTION F: Injuries Sustained
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Single Injury: Multiple Injuries | Multiple Injuries (List Below):
NOTES:
Task Factors:
SECTION G: Contributing Factors (Review All Six Categories)
☐ Does NOT Apply
☐ No Task Factors
☐ Awkward Load to Handle
☐ Bending Forward at Waist
☐ Extended Reach
☐ Heavy Load – Lift
☐ Heavy Load – Pull
☐ Hot Load – Pull
☐ Unknown
☐ Incorrect Tool
☐ Lifting Above Shoulders
☐ Procedure Not Followed
☐ Repetitive Motion
☐ Rushing
☐ Twisting the Trunk
S.O.P. - Standard Operating Procedure
Organizational
Factors:
Other (Describe):
☐ Does NOT Apply
☐ No Organizational Factors
☐ Communication
☐ Excessive Workload
☐ Job Design
☐ Job Training
☐ Planning
☐ Unknown
☐ Skill Training
☐ Staffing
☐ S.O.P. (Missing)
☐ S.O.P. (Not Up To Date)
☐ Other
☐ Does NOT Apply
☐ No Equipment Factors
☐ Defective Equipment
☐ Inappropriate Equipment
☐ Incorrect Equipment
☐ Unknown
☐ Equipment Noise > 85 dBA
☐ Equipment Recently Installed
☐ Equipment Vibration Excessive
☐ Equipment Failure
Equipment
Factors:
Other (Describe):
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☐ Missing Equipment
☐ New Equipment
☐ New Equipment Location
☐ Missing Maintenance
☐ Defective Safety Device
☐ Ineffective Safety Device
☐ Safety Devices Missing
☐ Missing Signage
☐ Materials Failure
☐ Safety Device(s) Failure
☐ High Force Requirement
☐ Labels Missing
☐ Labels Unreadable
☐ Inadequate Maintenance
☐ Inadequate Signage
☐ Does NOT Apply
☐ No Human Factors
☐ Inadequate Experience
☐ Experience Lacking
☐ Fatigue
☐ Illness
☐ Inadequate Knowledge
☐ Knowledge Lacking
☐ Unknown
☐ Language Difficulties
☐ Physical Limitations
☐ Pre Existing Condition
☐ Inadequate Skill
☐ Skill Lacking
☐ S.O.P. Not Followed
Human Factors:
Other (Describe):
S.O.P. - Standard Operating Procedure
Environmental
Factors:
Other (Describe):
☐ Does NOT Apply
☐ No Environmental Factors
☐ Floor Surface Inappropriate
☐ Floor Surface Slippery
☐ Floor Surface Uneven
☐ Floor Surface Wet
☐ Floor Surface Inadequate
☐ Unknown
☐ P.P.E. Restrictions
☐ Limited Light
☐ Limited Space
☐ Temperature (Too Hot)
☐ Temperature (Too Cold)
☐ Vision Obstructed
P.P.E. – Personal Protective Equipment
Other (Describe):
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Other Factors:
☐ Does NOT Apply
☐ No Other Factors
☐ Returning from Extended Leave
☐ Returning from Long Vacation
☐ Hazardous Behaviour
☐ Hazardous Condition
☐ Hazardous Situation
☐ New Worker (< 6 months)
☐ Inadequate P.P.E.
☐ Missing P.P.E.
☐ P.P.E. Not Worn/ Disregarded
☐ Unknown
☐ New/Unfamiliar Equipment
☐ New/Unfamiliar Hazardous Substance
☐ New/Unfamiliar Procedure
☐ New/Unfamiliar Process
☐ New/Unfamiliar Task
☐ New/Unfamiliar Tools
☐ New/Unfamiliar Working Conditions
☐ Sudden/Unexpected Weather Change
☐ Change in Normal Shift for New Shift
P.P.E. – Personal Protective Equipment
Other (Describe):
SECTION H: Describe What Happened
The TASK BEING PERFORMED when the event occurred was:
☐ URGENT | ☐ ROUTINE
Description:
The EQUIPMENT, TOOLS, SUBSTANCES being used prior to the event were:
Description:
The DETAILS OF THE EVENT (Keep in mind: What – How – Why)
In Your Opinion, the EVENT was the ☐ Preventable or was the event ☒ Not Preventable? (Check One)
Description:
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SECTION I: Corrective Action
Eliminate the hazard or reduce the risk to the lowest level achievable. Use the Hierarchy of Controls.
Hierarchy of Controls:
BEST CONTROL
EFFECTIVENESS

☐ ELIMINATE – Remove Design Out
☐ SUBSTITUTE – Replace with Something Safer
☐ ENGINEER – Isolate/ Guard/ Add Local Ventilation
☐ ADMINISTRATIVE – Train/ Schedule/ Signage/ Labels
☐ BEHAVIOUR – Follow Safe Practices/ Housekeeping/ Hygiene
☐ PERSONAL PROTECTIVE EQUIPMENT - Provide/ Fit/ Train
WHAT MAKES GOOD CORRECTIVE ACTION?
 It is cost effective |  It is reasonable |  It is doable |  It is specific
 It is focused on systems and processes, not on individual performance
 It does not create another hazard | It addresses the why or root cause
Provide specific action(s) to prevent this event or a similar event from happening again. Review and check
all those that apply. Provide the details on the corrective actions.
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☐
No Corrective Action
Required (WHY?)
Provide
Details:
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Communication
Emergency Preparedness
Equipment Program
Hazard Inventory
Housekeeping Program
Hygiene Control Program
Inspection Program
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Job Hazard Analysis
Knowledge Training
Leadership Training
Maintenance Program
Manufacturer
Materials Management
Medical Surveillance Program
Noise Control Program
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P.P.E. Program
Safety Device(s)
Skill Training
Task Analysis
Task Observation
Work Permit System
Work Procedure(s)
Working Alone Program
P.P.E. – Personal Protection Equipment
Corrective
Action 1
By Whom:
By When:
Click here to enter a date.
Corrective
Action 2
By Whom:
By When:
Click here to enter a date.
Corrective
Action 3
By Whom:
By When:
Click here to enter a date.
Corrective
Action 4
By Whom:
By When:
Click here to enter a date.
SECTION J: Investigator and Key Stakeholders
Investigated By:
RU Email:
Report Sent:
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Report Filled By:
RU Email:
Report Sent:
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Departmental
Safety Officer:
RU Email:
Report Sent:
☐
Supervisor:
RU Email:
Report Sent:
☐
RU Email:
Report Sent:
☐
RU Email:
Report Sent:
☐
RU Email:
Report Sent:
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Department
Head:
Dean/ Director/
Vice President:
HR Consultant:
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SECTION K: Signatures
I declare that all of the information provided is complete and true to the best of my knowledge. Sign and Date:
Type
Name:
Signature:
Type Name:
___________________________
Signature:
Date
Signed:
Date Signed:
___________________________
Click here to enter a date.
SECTION L: Checklist
REVIEW AND SELECT ALL THAT APPLY:
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Site Visited
Photos taken and attached
Sketch attached
Additional documentation attached
Appropriate persons/ departments
notified
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Injury to a Non-Ryerson Employee – Additional Steps Required
1. An electronic copy of this form (Internal AIE form) sent to irm@ryerson.ca
2. An electronic copy of this form (Internal AIE form) is sent to the University Insurance
Officer (cscanlan@ryerson.ca). Pictures must be taken and sent with this form.
☐
Injury to a Ryerson Employee – Additional Steps Required
1. An electronic copy of this form (Internal AIE form) sent to irm@ryerson.ca
2. Supervisor fills out the online WSIB Employer’s Report Form 7
http://www.ryerson.ca/content/dam/ehss/pdfs/forms/WSIB_EmployerReport_Form7.pdf
Signatures Obtained
Copy of signed report provided to worker
Signed scanned report sent to irm@ryerson.ca
Original signed report kept in department
Signed scanned report provided to local union
office of worker
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The Form 7 must be filled out online (no hand written copies)
A. Print three copies Ione for employee, one kept in the department, and on for HR)
B. Signed by Injured Worker and Supervisor
C. Signed form must be dropped off to HR within 3 calendar days of the event or pay $250
penalty
Additional Information
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INSTRUCTIONS FOR FILLING OUT THE ACCIDENT – INCIDENT – EXPOSURE (AIE)
FORM
WHAT TYPES OF EVENTS GET INVESTIGATED
Accidents, Incidents, Exposures, Significant Property Damage, Serious Near Misses, Critical Injuries, Critical Events
WHO INVESTIGATES
The supervisor (or their designate) of the person or the supervisor of the event/activity (Person = worker,
student, visitor, etc.)
WHO FILLS OUT THE FORM
The supervisor (or their designate) of the person or the supervisor of the event/activity (Person = worker,
student, visitor, etc.)
WHEN DOES THE FORM GET FILLED OUT
Within 24 hours of the event occurring or reported.
THE AIE REPORT IS FILLED OUT – WHAT NEXT
 SAVE as PDF
 SUBMIT electronic report to irm@ryerson.ca
 OBTAIN signatures
 SCAN signed copy and send it electronically to irm@ryerson.ca
 SCANNED signed copy is sent electronically to Key Stakeholders (Section J, Investigators and Key Stakeholders).
CRITICAL INJURIES AND CRITICAL EVENTS MUST BE REPORTED IMMEDIATELY
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There are legal requirements to report these specific types of injuries or events to various government agencies
within strict time lines. Become familiar with this list and the actions in the unlikely event that this should happen.
Everyone who reports to you should also be familiar with this list and the actions.
CRITICAL INJURIES
a death
a substantial loss of blood
burns to a major portion of the body
the amputation of a leg, arm, hand, or foot
the fracture of a leg or arm
the loss of eye sight in an eye
placing life in jeopardy
producing unconsciousness
CRITICAL EVENTS
a fire in a room where people work
a major structure failure
an explosion
the collapse or failure of lifting equipment
the major release of a hazardous substance
flooding (a substantial amount)
IMMEDIATE ACTIONS ARE REQUIRED – SEE INSTRUCTIONS BELOW:
STEP 1
STEP 2
STEP 3
STEP 4
STEP 5
Assist the Injured Person
Call Security (Internal Phone Dial 5040) – Outside Phone Dial 416-979-5040
Prevent further injuries or damage to property
Secure the scene and DO NOT DISTURB IT – authorities may need to investigate
Call Environmental Health and Safety (EHS) at 416-894-3340
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