Notice of Occupational Disease: Report Form

(As required under Section 52 (2) of the Ontario Occupational Health and Safety Act)

Section 1:To be completed by Employerif you are a workplace to which the Health Care and Residential Facilities Regulation OR Industrial Establishments Regulation applies.

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© Public Services Health and Safety Association, 2017

Organization Information

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© Public Services Health and Safety Association

Name: Click here to enter text.

Type of Business: Click here to enter text.

Address: Click here to enter text.

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© Public Services Health and Safety Association

Place of Occurrence

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© Public Services Health and Safety Association

☐Client care area

☐ Public area on site

☐Community

☐Client’s home

Other: Click here to enter text.

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Date and time of occurrenceClick here to enter text. / Date and time occurrence reportedClick here to enter text.
Incident reported to Click here to enter text.

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© Public Services Health and Safety Association, 2017

Description (Please describe the nature of the illness and the circumstances that gave rise to the illness in the space below)

Nature of the illness. / Click here to enter text. /
Circumstances that led up to the illness/ occurrence. / Click here to enter text. /
Description of the cause or suspected cause
(See bottom of page 2 for examples of Immediate and Root or Underlying causes). / Click here to enter text. /
Other information: Click here to enter text.

Steps taken to prevent a recurrence

Please indicate actions taken to prevent a recurrence or further illness (e.g., initiated outbreak response plan with enhanced precautions and environmental cleaning, contacted Public Health, discussed at JHSC and Infection Control Committee etc.)

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© Public Services Health and Safety Association, 2017

Affected Employee(s):

Employee Name: / Address: / Physician name and contact Information:
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Dates employees were affected by the illness: Click here to enter text.

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© Public Services Health and Safety Association, 2017

Immediate Causes:

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© Public Services Health and Safety Association, 2017

Substandard Condition: Contributing conditions such as machinery/equipment, housekeeping, physical agents, chemical agents, personal protective equipment, temperature (heat/cold), etc.

Substandard Practice: Contributing actions such as unauthorized equipment use, improper body motion, working at unsafe speeds.

Root or Underlying Causes:

Job Factors: Work procedures, purchasing, equipment/machine/tool design, training program, engineering controls, inadequate/inappropriate/unavailable equipment etc. give examples related to equipment, materials, environment, processes etc.

Personal Factors: Physical restrictions, lack of training, motivation, inadequate capability, competency, compliance, enforcement etc.

Section 2:To be completedby Employer if you are a workplace to which the Industrial Establishments Regulation applies

Name of Witnesses:

Name: / Address:
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Other: Click here to enter text.

Description of the Machinery or Equipment involved:

Section 3: Organizational tracking of reporting. (Optional)

Reported to Ministry of Labour? / ☐Yes ☐ No If yes, indicate date and by whom. Click here to enter text.
Reported to JHSC or HSR? / ☐Yes ☐ No If yes, indicate date and by whom. Click here to enter text.
Reported to Trade Union (if any)? / ☐Yes ☐ No If yes, indicate date and by whom. Click here to enter text.
Reported to WSIB (Form 7) if applicable? / ☐Yes ☐ No If yes, indicate date and by whom. Click here to enter text.

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© Public Services Health and Safety Association, 2017