Youth Apprenticeship - Incident Form
Youth Apprentice Name
*
First Name
Last Name
Date of Incident
*
-
Month
-
Day
Year
Date
Time of Incident
*
Location of Incident
*
Please describe what happened - the tasks being performed and the sequence of events. (If these details are provided in your local workplace incident reporting documents, please upload a copy below.)
*
If available, please include a copy of your workplace incident reporting form
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Was anyone injured?
*
Yes
No
Describe the injury
Was medical treatment necessay
Yes
No
The student received medical treatment
onsite at place of employment
student was transferred for medical treatment
other
Where was the student transported to receive medical treatment?
Were there witnesses to the incident
*
Yes
No
Witness Name
First Name
Last Name
If you know the witness's email or phone number, please enter here:
Has the family of the Youth Apprentice been notified?
*
Yes
No
Name of person completing the form
*
First Name
Last Name
Email of person completing the form
*
example@example.com
Role in the organization
*
Signature
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: