Forms Cabinet

Injury Forms:

All incident and injury forms can be found on the Office of Environmental Health and Safety site.­  ­Always report an incident or injury to the Acting Chair (Admin) or to the Department Safety Officer.

Minor Injuries: Forms­

Minor injuries are those injuries that do not involve medical attention. If someone is uses any item from a Lab or Field First Aid Kit, that person must report what they are using from the kit on the First Aid Report Sheets. By recording the incident you have a record of the injury should the incident become more severe that first realized; then there is a permanent record. The First Aid Report Sheet  must be filled out and given to the Assistant Chair (Admin). These records must be kept for three years.

First Aid Form

Serious Incidents and Injuries:

There are many EAS Personnel who have First Aid Training. (All EAS personnel involved with any EAS Field School are required to have current CPR and First Aid Training.)

When a serious injury has occurred it is important to know where the nearest First Aid Kit is located and who to call. If an ambulance is required, call 911 immediately. If you are working in the field, call the local ambulance or contact the STARS Emergency Link Centre @ 1-888-888-4567 or #4567 on cellular. Once the situation has been controlled and dealt with, the Incident & Investigation Reports need to be filled out and sent to the appropriate personnel on campus.  If the injured person needs to seek medical attention, then WCB forms have to be filled out and filed within 72 hours.

Faculty/Department Incident & Investigation Report

Workers Compensation form – Employer’s Form

Worker’s Compensation form – Worker’s Report

Both the injured worker and the employer have forms to fill out and submit to the U of A’s Human Resource Department.  Injuries requiring a WCB form need to be reported to your department,  EH&S and  Human Resources.

When reporting an incident or injury, you must take steps to protect people’s privacy. The information surrounding an incident can be given only to those individuals who are directly involved with ensuring an injured worker’s safety and those persons involved in ensuring that a repeat occurrence does not occur.

 

Chemical Spills Form

The following form can be used to report a chemicals spill in the lab. There are three objectives to the form:

  • Were there any lab personnel injured, if so did they seek first aid or medical treatment for the injury?
  • How did the spill occur and what steps are necessary to avoid a repeat occurrence?
  • Follow up – has a new protocol been established to prevent a repeat accident and were all safety supplies replenished after the event?

Spill or Environmental Release

 

Laboratory Close Out Forms:

The following form must be filled out whenever a Faculty Member:

  • Retires and vacates the lab
  • Moves to another lab
  • Renovations are being done in an existing lab

The purpose of the form is for the safety of new occupants to a lab, where the old chemicals and dangerous goods have been removed prior to their occupying of the space. When renovations occur, the Physical Plant workers must not be endangered by existing chemicals or equipment in the lab.

Lab Closeout Guidelines

 

Clearance to Work in Hazardous Areas Forms:

When minor renovations are to be done in an existing lab, the following form must be filled out. This form is intended to keep the renovator safe from the dangerous goods stored or dangerous equipment in the lab.

Clearance to Work Form

 

Checklist for Workstation Form:

This checklist is intended to provide you with basic information so that you can check the current set up of your furniture and equipment. It may help to reduce your risk of repetitive strain injury from working at a desk. If you require an assessment, contact your supervisor who will contact the Occupational Health Nurse for an assessment.

Ergonomic Assessment form

 

Respirator Health Questionnaire:

Before you begin to wear any type of respirator, you need to be sure that you do not have health conditions that would cause you to have serious problems donning a mask.  The appropriate  type of mask to use will depends upon the hazards of the material/s you are working with.  You need to fill out a questionnaire form and sent it to the Occupational Health Nurse;  then a Respirator Fitting Test can be done.

Respirator Health Screening Form