Lawrence S. Bloomberg Faculty of Nursing

Clinical Incidents Form

Form
Personal Information
Data Collected WSIB Incident
Data Collected Non-WSIB Incident
Data Collected by the System
  • The safety of our students in clinical education settings is a high priority and we strive to provide our students with safe and quality learning experiences.

  • PERSONAL INFORMATION

    The University of Toronto respects your privacy. The information on this form is collected pursuant to section 2(14) of the University of Toronto Act, 1971.  It is collected for the purpose of administering admission, registration, academic programs, university-related student activities, activities of student societies, financial assistance and awards, graduation and university advancement, and for the purpose of statistical reporting to government agencies. Your IP address and browser version are collected for Information Technology troubleshooting, as may be required.  At all times, all data is protected in accordance with the Freedom of Information and Protection of Privacy Act. If you have questions, please refer to www.utoronto.ca/privacy OR contact the University’s Freedom of Information and Protection of Privacy Office at 416 946-5835, Room 104, McMurrich Bldg., 12 Queen’s Park Crescent West, Toronto, ON, M5S 1A8.

    I agree to have the information in this form plus my IP address and browser version be collected and stored electronically and I understand it will be protected in accordance with the Freedom of Information and Protection of Privacy Act. I understand that the information will be shared and viewed only by those who need to know. I also understand this form will be retained based on the University’s best practice guidelines for records retention, after which it will be destroyed in accordance with Information Technology Security best practices.

  • The following information is collected for a WSIB incident


    Required Data

    Program

    Student first Name and Last Name

    Date of Incident

    Course Code

    Term

    Site and Unit

    Clinical Instructor/Preceptor Name

    Exposure to Bodily Fluids (drop down selection including N/A option)

    Describe circumstances of the incident (time, location, description)

    Optional Data

    Physical Injuries (drop down selection including N/A option)

    What was the follow up for this incident?

    Was an agency incident report completed?

    Any additional follow up required?

     

  • The following information is collected for a Non-WSIB incident


    Required Data

    Program

    Describe circumstances of the incident (time, location, description)

    Optional Data

    Student First and Last Name

    Date of Incident

    Course Code

    Term

    Site and Unit

    Clinical Instructor/Preceptor Name

    Violence (drop down selection)

    Medication Errors (drop down selection including N/A option)

    Procedure Error (drop down selection including N/A option)

    Administrative Error (drop down selection including N/A option)

    Near Misses (drop down selection including N/A option)

    What was the follow up for this incident?

    Was an agency incident report completed?

    Any additional follow up required?

  • This data is automatically collected by the system for all types of clinical incident reports


    Date and Time of the Form Submission

    Browser Version

    IP address (does not identify the name of the individual)

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