Incident / Accident Report Form
Part 1
Name:
Department/Program:
Employee:
Student:
1. Campus or Location of Incident:
`
Welland Campus
Visitor:
NOTL Campus:
MMC
Other:
Details of the Accident Location (Room Number, area, etc):
Part 3
2. Date of Incident:
Time:
AM:
PM:
3. Date Incident Reported:
Time:
AM:
PM:
4. Injury Reported to:
5. Name of Manager/Supervisor:
Part 4
6. Classification:
Injury/Illness:
Part 5
7. Body Part:
Property Damage:
Left:
Near Miss:
Right:
Other:
Body System:
8. Description of Injury (i.e. cut, burn, bruise, etc):
Part 7
9. In your own words please provide a brief explanation of how the injury, incident, or
near miss occurred:
Part 8
10. In your own words please provide details of how this could have been prevented:
Part 9
Additional Comments:
Part 10
Functional Abilities Form Provided to health care professional:
Yes
No
N/A
Niagara College has a modified work program, our priority is an Early and Safe Return to Work.
Form to be completed and submitted to the Environmental Health and Safety Department Located in
L22B at the Welland Campus, or Email to ehs@niagaracollege.ca