ETFO-UCL Workplace Violence Survey

The survey is for ETFO-UCL to monitor the Health and Safety incidences in the UCDSB worksites. Please complete this survey each and every time you complete a Violent Incidence form. This form is to inform ETFO-UCL of violent incidences - it is not a replacement for the official UCDSB form. An ETFO-UCL Released Officer may contact you as a follow-up.

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* 1. Last name, First name

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* 2. School

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* 3. Email address

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

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* 5. Assailant

Parent

Student

Visitor/Member of the Public

Other (please specify)

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* 6. 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 it is reasonable for a worker to interpret as a threat to exercise physical force against the worker, in a workplace, that could cause physical injury to the worker

Pleasee 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 threat is imminent and dangerous.

pinching

hair pulling

verbal

spitting (if risk of infection medical attention ought to be sought - contact ETFO-UCL if in doubt)

scratching

scratching (blood) - contact ETFO-UCL immediately

biting (no broken skin)

biting (broken skin) - (if risk of infection medical attention ought to be sought - contact ETFO-UCL if in doubt)

threatening

pushing

kicking

striking

sexual

object thrown

Other (please specify)

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* 7. Was medical attention sought/Will medical attention be sought?

Yes

Other (please specify)

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* 8. INCIDENT AND INJURY INFORMATION

Date / Time

Date

Time

AM/PM

Please note that if medical attention was sought or will be sought then, for your own protection, you must complete a WSIB form (and have your physician also complete a WSIB form).