Parklane Employee Report

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* All required fields are red

Employee Details

(click the 'Lookup' button below to search for an employee)

Employee Name

Employee ID

Job Class / Position

Employee Union

City

Gender

Department

Birth Date

Hire Date

Employment Details

Supervisor

Reporting Information

Your Telephone Number

Your Email Address

Incident Description

Incident Classification

I am reporting a hazardous situation or near miss, where there was no personal injury.

I was injured. I did not receive first aid or I received first aid from someone other than a physician or other health care professional. I returned or will be returning to work.

I was injured. I received medical attention at a hospital or at a medical clinic or at a doctor's office. I returned or will be returning to work.

I was injured and I will be off from work as the result of my injuries.

Date of Incident

Time of Incident

Was Violence or Harassment a part of this incident?

Yes No Unknown

Violence, Harassment Details

Did the situation involve physical violence?

Yes No

CategoryType of physical violence against worker

Exercised	Punching	Striking	Spitting	Scratching	Pulling
Attempted	Biting	Pushing	Kicking	Sexual
Threatened	Other

Did the situation involve harassment?

Yes No

CategoryType of harassment against worker

Comment(s) made	Verbal	Written / Email	Stalking	Telephone / Texting
Conduct	Destruction of Personal Property	Bullying	Malicious Rumour
	Other

Were weapons involved?

Yes No Unknown

Type of weapons used

Brick / Stone	Gun / Firearm	Stick / Bat / Bar
Explosive Device / Bomb	Knife
Glass / Bottle	Needle / Sharps
Other

Is the aggressor a third-party to the company? (ie. customer, visitor, patient, etc.)

Yes No

What is the first aggressor's relationship to the worker?

If 'Other' is selected, please explain:

If applicable, what is the second aggressor's relationship to the worker?

If 'Other' is selected, please explain:

Is the aggressor an employee of the company?

Yes No

Click on the 'Lookup' button to search for an employee's name, or type their name in the space provided.

Employee's Name

Is domestic violence a factor in this incident?

Yes No

Has the aggressor been involved with any previous violent incidents with staff?

Yes No

Please Explain

Aggressor Identification

(Name, Address, Age, Height, Role)

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Were the Police summoned for this incident?

Yes No

Was a police statement or report taken?

Yes No

Have charges been laid, or are pending?

Yes No

Police Incident Number (if known)

Has Government Labour / Regulatory Body been advised?

Yes No

Did they visit the workplace?

Yes No

Did they advise by telephone/fax/email/letter?

Yes No

Did they write or issue an order?

Yes No

Incident Details

Witness(es) of Incident

Location where incident occurred

What were you doing at the time of this incident?

(ex. cutting open a box, pushing cart, etc., provide more detail)

You have 960 characters left

What happened to cause this incident?

(Contributing factors related to people, process, equipment, materials, and environment)

You have 960 characters left

Additional Information: Provide details that are relevant or significant.

Examples: -Was there a specific incident to cause the injury?
-Description and weight being lifted or moved (kg or lbs)
-How long was the task being performed on the day of the injury?
-How long was the task performed in the last hour leading up to the reported injury?

You have 960 characters left

Injury Details

Describe your Injury:

Affected Areas (check all that apply):

Head Face Eye(s) Ear(s)	Teeth Neck Chest Upper Back	Lower Back Abdomen Pelvis
Left Right Shoulder Arm Elbow Forearm Wrist	Left Right Hand Fingers Hip Thigh Knee	Left Right Lower Leg Ankle Foot Toes

Other

Medical

Did you seek medical treatment?

Yes No Unknown

Where were you treated?

On Site Clinic

Ambulance

Health Professional Office

Medical Clinic

Emergency

Admitted to Hospital

Date Employee Sought Medical Treatment:

Date Employer Learned

If the employee was treated by a Health Care Professional, enter that person's name

Health Professional's Address

Enter Additional Comments

You have 960 characters left

First Aider / Medical Attendant

Telephone Number

Date of First Aid

Parklane Employee Report

Introduction

Employee Details

Employment Details

Reporting Information

Incident Description

Violence, Harassment Details

Incident Details

Injury Details

Medical

Message to Employee