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Unpaid Work/Education Placement – Accident/Incident Report

All form fields are required.

Date Information
AM/PM
 
AM/PM
Personal Information
Placement information
Accident/Incident information
Has student had a previous similar injury?
Were any placement hours missed due to this injury?

Collection and use of Personal Information

The information obtained on this form is used by the college to administer unpaid work/education placements with an employer as part of a course or program of study, and may be shared with the Ministry of Advanced Education and Skills Development, Workplace Safety & Insurance Board, hospitals, physicians and college insurance carriers. This information is collected and used under the authority of the Ministry of Colleges and Universities Act, R.S.O. 1990, c.M.19, and Regulation 770, the Workplace Safety & Insurance Act, and the Occupational Health and Safety Act and Regulations.

Questions about the collection or use of this information should be directed to Occupational Safety Office, Conestoga College, 299 Doon Valley Drive, Kitchener, Ontario, N2G 4M4.

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