Occupational Health Safety & Wellness Concern Form

Site
Grey Nuns Hospital (GNH)Edmonton General Continuing Care Centre (EGCC)Norwood112th CampusWork from Home

First Name

Last Name

Department

If we need to contact you about this OHS&W concern and you want to be reached at a specific phone number or email address (or both), specify them below.

Phone #

Email

Date of incident

Time of incident

Please refrain from using the names of patients, clients, residents, staff or doctors involved.

Describe the Nature of the Incident

What is the Suspected Hazard?

Any Injury or Disease Related to Concern (if known)?

Who was the Supervisor you Reported Incident to?

Date Reported to Supervisor: