Mohawk PSW/Nursing – Safety Incident Report Form (Students)

We would like to create a safe environment for students, staff and patients/clients/residents by ensuring a process is in place to manage and learn from safety incidents. Our focus is on identifying and decreasing safety risk and ensuring that the reporting of incidents leads to learning opportunities and systems improvement. We recognize that mistakes do happen and we see them as opportunities to learn, we encourage reporting and want to ensure the process is free from blame.

Please note this information will be kept confidential and shared only with those necessary for incident follow-up and process improvement.

Student Steps for an Accident or Injury while out at placement:

1. Notify the facility and your preceptor of the injury or accident as soon as possible

2. Complete any forms that the facility requests related to the accident and or injury

3. Notify your clinical supervisor and clinical coordinator of the accident and or injury

4. The student will fill out the Microsoft form below:

You can fill out the form at this linkLinks to an external site., or scan the QR code below.

5. The student will send a copy of the form that was requested to be filled out by the facility to ohsmohawk@mohawkcollege.ca *please ensure to cc the clinical coordinator in the email to OHS Mohawk* (jordana.taylor@mohawkcollege.ca)

6. In the event the facility does not require the student to fill out any documentation please let the clinical coordinator know as soon as possible

7. ***Please wait for follow up from the FPS or clinical coordinator after all steps above have been completed***

What is the WSIB Insurance coverage?

You are covered under the Workplace Safety and Insurance Board (WSIB) provided by the Ministry of Training, Colleges, and Universities (MTCU) or private insurance coverage (ACE-INA) can be available to you through the MTCU depending on the Placement Employer’s coverage.

If the assigned agency is not covered under WSIB (rare) you will be covered under ACE-INA. Otherwise, you are covered under WSIB.  When starting your placement, the placement site must indicate if they are covered under WSIB or not.

In the event of injury or disease while on placement you must immediately report the accident/injury to the Placement Employer (your supervisor). The Placement Employer must complete an accident report with you and provide a copy to the Mohawk College representative (your FPS). If a workplace Insurance claim is reportable to WSIB or ACE-INA, the FPS will complete a Postsecondary Student Work Placement Insurance Claim Form, which requires signatures from the Placement Employer, the student, and the FPS. This may result in student information being disclosed to the MTCU. The FPS will coordinate this process. For more information regarding this process, visit the Guidelines for Workplace Insurance for Post-Secondary Students webpage. Contact the Field Placement Specialist for assistance. Sign this form in acknowledgement of the insurance coverage available to you.

Training Agencies are required to have a declaration signed by the student indicating that s/he understands that s/he has WSIB coverage while on clinical work placements (the signed Placement Confirmation Form will suffice).  All WSIB procedures must be followed in the event of injury/disease.

Within three days of learning of a work-related injury/disease the Placement Employer must complete WSIB Form 7 Employer’s Report of injury/disease (which can be accessed from the WSIB website and must be sent to WSIB). The Training Agency may submit this on the Placement Employer’s behalf, providing a letter to authorize is signed by the Placement Employer (FPS will coordinate this). The Placement Employer will need to provide their WSIB #, Firm #, an accident report, sign the MTCU Unpaid Work Placement Insurance Claim Form, and the Letter of Authorization.

Completion of Form 7 Employer’s Report of injury/disease is the joint responsibility of the Placement Employer and the Training Agency.

The Placement Employer is considered to be the “employer” for unpaid trainees. As such, the Placement Employer must authorize the Training Agency (Mohawk) to act as the representative with WSIB for the claim being submitted. A Letter (template) of Authorization to Represent the Placement Employer can be provided through the FPS.

The FPS should be contacted ASAP, along with the Clinical Supervisor by the student and/or the facility supervisor should an incident causing injury on placement occur so that they may assist in this process.