The survey is for the AMOT Local to monitor the Health and Safety incidences in the AMDSB work sites. Please complete this survey each and every time you complete an Employee Accident/Incident form. This survey is to inform the AMOT Local of violent incidences- it is not a replacement for the official AMDSB form. An AMOT Released Officer may contact you as a follow up.

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* 1. Date of Incident

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* 2. Last name, First name:

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* 3. School:

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* 4. Email address:

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* 5. Phone # where you can be reached most easily (please note if home/office/cell)

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* 6. Assailant:

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* 7. Initials of Assailant

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* 8. The Occupational Health and Safety Act defines workplace violence as:
*The exercise of physical force by a person against a worker, in a workplace, that causes or could cause physical injury to the worker;
*An attempt to exercise physical force against a worker, in a workplace, that could cause physical injury to the worker;
*A statement or behaviour that is reasonable for a worker to interpret as a threat to exercise physical force against a worker, in a workplace, that could cause physical injury to the worker.

Please check which of the following pertains to this incident:

In all of these incidents, consider calling 911 should you not be able to reach the school response team and the threat is imminent and dangerous.

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* 9. Do you frequently feel unsafe in this classroom or in this school?

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* 10. Have you completed the Employee Accident and Incident Report (Form 175a), made a copy for your files, and submitted the original to your principal?

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* 11. Have you emailed a copy (screen shot) of the Employee Accident and Incident Report to the OT Local office at etfokimfin@gmail.com?

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* 12. Was/will medical attention be sought?

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* 13. INCIDENT AND INJURY INFORMATION

Date / Time
Please note that if medical attention was sought or will be sought then, for your own protection, you AND your physician must complete a WSIB form.

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