Appendix 16
 District School Board of Niagara

Coop Student Accident Report

INSTRUCTIONS FOR COMPLETING THIS REPORT:

The Co-op Teacher must complete this form and have student sign below, if possible, to make a claim with
 the Workplace Safety & Insurance Board.
Once signed, attach copy of Work Education Agreement Form.
 SEND THIS REPORT AND Work Education Agreement FORM to ANNE HUSKA, Human Resources Dept., within 48 hours of accident
FAX FORMS IF AT ALL POSSIBLE to: 1- 9O5-641-0071
 

Student Name Home Phone No
Home Address:
CO-OP Work Location   School
Date of Birth Social Ins. Number
Working Hours: From _______to ________    Days Worked Per Week_
Date of Injury: ____________ 20.___  Time of Injury:
Date and Time Reported   Injury Reported to:

What was student doing when he/she was injured: _________________________________________________________

 ________________________________________________________________________________________________

 ________________________________________________________________________________________________

What happened to cause injury/disease? ________________________________________________________________

Describe injured part of body: ___________________  Right/Left/Upper/Lower?__________________________________

Name of Witness: ____________________________  _____________________________________________________

Will you lose time from Co-op? 0 YES 0 NO                       Date Last Worked: _______________________________________

Is this a recurrence of injury? 0 YES 0 NO                          Have you been injured at work before? 0 YES 0 NO

The new Workplace Safety & Insurance ACT (1997) (WSIB) states that an employee must file  his/her claim with WSIB. By signing be/ow,  you have  fulfilled your accident reporting obligations. You may be asked for further information from WSIB.
         

 STUDENTS SIGNATURE: By signing below, I am claiming benefits under the Workplace Safety and Insurance Act, 1997, for a work-related  injury or disease. I am also authorizing any health professional who treats me to provide me, the Ministry of Education and Training, and the Workplace Safety and Insurance Board with information about my functional abilities on the Workplace Safety & Insurance Board's  "Functional  Abilities for Timely Return to Work" form. I need only sign this if  I sought health care or if I lost time from work from this accident.

  Student Signature: _____________________________________________________  Date: ____________________

Co-op Teacher Completing Report _____________________________________________________________________

Signature of Principal of School _______________________________________________________________________

Cooperative Education Student Handbook |