Corporate Workplace Safety Section, Human Resources Department

Physical Address: 120 King Street West, 9th Floor

Phone: 905-546-2424 Ext. 4176 Fax: 905.546.2650

Email: lfenyves@hamilton.ca

City of Hamilton

City Hall, 71 Main Street West

Hamilton, Ontario,

Canada L8P 4Y5

CITY OF HAMILTON - CORPORATE SAFETY PROCEDURE

DEVELOPED BY: CORPORATE WORKPLACE SAFETY SECTION Procedure # COH-RQ-WI-005 DATE: November 17, 2005 APPROVED BY: Corporate Management Team

Revised: January 10, 2007

VIOLENCE IN THE WORKPLACE PREVENTION PROCEDURE I. SCOPE: This Violence in the Workplace Procedure supports the City of Hamilton Violence in the Workplace Prevention Policy by outlining specific preventive actions to discourage and prevent acts of violence in the workplace before they occur. The procedure further outlines corrective measures to take in the event acts of violence occur in spite of all reasonable effort to prevent them and the measures that can be taken to support employees who are affected by such violence. For definitions see Violence in the Workplace Prevention Policy. II. PURPOSE: The City of Hamilton is committed to providing a safe and healthy work environment. Integral parts of achieving this goal are the design of work practices, operational procedures and staff training programs to prevent workplace violence. III. RESPONSIBILITY: Everyone is responsible for creating and maintaining a safe workplace to the extent of each person's authority and ability to do so. It is the responsibility of every City of Hamilton employee to assist and cooperate in making the workplace as safe and secure as possible. This policy applies to all employees of the City of Hamilton, including but not limited to regular, temporary and contract employees, students, volunteers, and interns. Members of the general public, visitors to City facilities, or individuals conducting business with the City of Hamilton, are expected to refrain from any form of violence. The City will take any necessary steps to ensure a workplace free from violence. Since all employees have the right to work in an environment free from violence, all employees share the responsibility to support a violence free workplace.

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SPECIFIC RESPONSIBILITIES: A) WORKPLACE SAFETY SECTION and/or DEPARTMENT SAFETY/WELLNESS SPECIALISTS:

o Will actively monitor industry standards and available current information on "Violence in the Workplace Prevention" issues and provide information to and consult with department management to allow for the most effective implementation of Violence in the Workplace Prevention programs.

o Will participate in the investigation of reported violence related incidents in the workplace, as requested, and will assist department management and Joint Health and Safety Committees in implementing proper programs/controls in response to such incidents.

o Will review, analyse and track all reported incidents of violence in City of Hamilton facilities and operational activities.

o Will review and provide input on all work practices, operational controls and training programs as may

be developed by departments to address specific department needs. B) DEPARTMENT/S:

o Departments are responsible for implementing this procedure and for establishing specific program modules and controls to prevent incidents of violence in their workplace/s. All violence prevention controls must be developed in consultation with the respective Joint Health and Safety Committee/s and be reviewed and approved by the Workplace Safety Section prior to implementation.

o Each Department will be required to establish a “Department Implementation Team” to be headed

up by either a Department Wellness/Safety Specialist or a member of the OHS Advisory Group or designate, to facilitate the implementation and continued visibility of the Violence in the Workplace Prevention Policy and Procedure.

IV. MANDATORY PROGRAM COMPONENTS: In developing work practices, operational procedures and staff training programs to prevent workplace violence, specific circumstances appropriate to each Department's operation must be considered. Such planning and strategizing will be conducted on City workplaces and will include consultation with workplace stakeholders. The Community Services Division of the City of Hamilton Police Department may be consulted prior to any recommended controls being considered for implementation. Contact members of this Division by telephone at 905-546-4906 or 905-540-6664 for information on “crime prevention through environmental design audits” for your workplace. When implementing this procedure the following four components must be included, as a minimum: 1. VIOLENCE HAZARD ASSESSMENT: The potential risk of violence in particular workplaces must be assessed. Each Department shall arrange for a hazard assessment to be conducted at each work location, in consultation with the appropriate Joint Health and Safety Committee/s, the Department Safety/Wellness Specialist if applicable, representative of the OHS Advisory Group and/or the Workplace Safety Section.

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As part of such assessments, all employees at the work location will be afforded the opportunity to voluntarily participate in a Hazard Assessment Questionnaire (attached as Appendix A). The Hazard Assessment Questionnaire will be completed in a suitable manner determined by the department management in consultation with the Joint Health and Safety Committee. Furthermore, Management, in consultation with the Joint Health and Safety Committee, may modify the questionnaire for the specific work location, to properly reflect the specific hazards identified. When any such modifications are contemplated the Workplace Safety Section must be consulted prior to implementation. 2. SIGNS AND NOTICES: Each Department will ensure that appropriate signs, (attached as Appendix B), indicating the City of Hamilton does not tolerate any acts of violence in the workplace, are posted in conspicuous areas throughout the Department. (Conspicuous areas include lunch rooms, reception areas, waiting rooms and other similar areas to which workers, guests and members of the public have access.) 3. EMERGENCY PLANS:

Departments are responsible for developing and implementing departmental Emergency Plans to address issues involving severe acts of violence (weapons involvement, multiple injuries, etc.). This review shall be conducted by the department implementation teams in consultation with the Wellness/Safety Specialist if applicable, the Joint Health and Safety Committee and the Workplace Safety Section.

Many departments already have an emergency action plan that describes procedures to follow during a fire or other similar emergency, such as bomb threats. Such existing plans, with appropriate modifications, may be utilized for workplace violence related emergencies. The plan needs to be specific to the type of facility, building and workers it covers. The plan shall be updated and reviewed with workers annually, particularly if there is turnover among employees or a change to the facility or a work process. For information on the required contents of an “emergency action plan” please see list (attached as Appendix C). 4. INFORMATION/TRAINING: Training is a critical component of any violence prevention strategy. Training is necessary for employees, supervisors, and staff members at any work location where responding to an incident of workplace violence may occur. Providing appropriate training informs employees that management will take threats seriously, encourages employees to report incidents, and demonstrates management’s commitment to deal with reported incidents. Training sessions will be conducted in accordance with the “Corporate Training Program” developed by Human Resources. Each Department, in consultation with the Joint Health and Safety Committee, will determine the most appropriate module/s of the Corporate Training Program to be delivered to their employees, based on the information gathered through the “hazard assessment – for violence in the workplace”. Departments in specialized high risk occupations such as By-Law Enforcement, Parking Control, Animal Control and various Inspection type occupations shall be required to implement available specialized training programs for employees. The course curriculum for such specialized programs must be submitted to the Workplace Safety Section for review to ensure consistency with this procedure.

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V. PROCEDURE FOR REPORTING AND INVESTIGATING ACTUAL OR POTENTIAL INCIDENTS OF WORKPLACE VIOLENCE: All reports of incidents or potential incidents of violence will be taken seriously and will be dealt with by the immediate supervisor in an appropriate and timely fashion. Reporting Emergencies: (Immediate danger; weapons involvement; physical injury related to violent behaviour; and obvious signs of abusive threatening behaviour) - For threats of violence, assaults or other violent incidents contact your supervisor immediately, if possible, OR CALL 911 immediately. Critical information must be provided including the nature of the incident; whether emergency services are required; whether perpetrator(s) are still present; whether weapons are involved; etc. After request for Police involvement and proper control of the emergency the event particulars shall be recorded by the supervisor on the “Critical Injury or Major Incident Report”, (attached as Appendix D). The supervisor, in consultation with the Wellness/Safety Specialist if applicable, a representative of the Workplace Safety Section, and a Human Resources Department, Labour Relations Officer or designate, may request the participation of other workplace parties to review the details surrounding the situation and determine the appropriate corrective action to resolve the issue. Reporting Non-Emergencies: (Verbal threats; actions and/or activities that may in the future lead to activities that may result in an emergency) Employees are encouraged to report threatening statements or behaviour that gives one reasonable grounds to believe that there is a potential for workplace violence immediately to the immediate supervisor, who will determine the appropriate response. Such reports may assist in identifying patterns of potential violence and may assist in the prevention of emergency situations in the future. The immediate supervisor, once made aware of such allegations, may contact the Wellness/Safety Specialist if applicable, a representative of the Workplace Safety Section, or a Human Resources Labour Relations Officer or designate, for advice and direction as may be necessary. The supervisor, in consultation with the Wellness/Safety Specialist if applicable, a representative of the Workplace Safety Section, or a Human Resources Department, Labour Relations Officer or designate, may request the participation of other workplace parties to review the details surrounding the situation and determine the appropriate action to resolve the issue. Workplace violence may extend off City property and may occur outside of normal working hours. Therefore this procedure will apply for any of the above listed behaviours that are determined through investigation to stem from, or are related to or can be linked back to the individuals’ employment with the City.

Detailed Investigation: The supervisor, in consultation with the Wellness/Safety Specialist, a representative of the Workplace Safety Section, or a Labour Relations Officer or designate may initiate a detailed, formal investigation consulting with other workplace stakeholders, as necessary, and initiate appropriate corrective action as may be determined through the investigation. Such a detailed investigation may be commenced on request by any stakeholder involved with the incidence of violence.

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If at the initial stages of the investigation it is determined that the issue being reviewed is an issue of “HARASSMENT AND DISCRIMINATION” the violence related investigation will be terminated and the issue processed to the Human Rights Specialist immediately for review. The investigation may result in the matter being further dealt with under the provisions of relevant collective agreement/s or through the Courts as may be deemed appropriate. A report will be filed using “the City of Hamilton Critical Incident or Major Incident Investigation Report” form (attached as Appendix D). During investigations fairness, impartiality, privacy and confidentiality issues as well as legislative requirements will be a primary consideration. Support Services/Medical Assistance: In the event of an incident of workplace violence resulting in physical injury, access to appropriate first aid or medical aid will be provided by Supervisor, as required under the WSIB Act. Ambulance or Police may be contacted depending on the severity of the injury. Once the injured employee has received the required care, the Supervisor will complete the appropriate "Report of Workplace Injury or Occupational Disease" form, as in any other incident involving workplace injury (attached as Appendix E), to ensure proper adjudication of the workplace injury by the WSIB. In cases where other support services are deemed to be required such as access to Employee/Family Assistance Program (EFAP) the immediate supervisor shall advise and assist the employee to seek such service, and/or initiate the appropriate response. In cases where the Critical Incident Peer Support Team (CIPST) involvement is required, the immediate supervisor shall contact the CIPST Coordinator immediately at ext. 2642 for assistance to seek such service, and/or initiate the appropriate response. VI. INSTRUCTION TO EMPLOYEES: All employees of the City of Hamilton are encouraged to report any legitimate intimidation, threats or acts of violence. Employees should be confident that issues reported to their immediate Supervisor/Manager will be treated with sensitivity, fairness and impartiality, while maintaining privacy and confidentiality considerations at all times. This procedure will be posted on all applicable City of Hamilton web pages (e-Net/You Should Know/Workplace Safety and WSIB/Corporate OHS Policy, Procedures and Guidelines; HR Policy and Procedures web page; and City of Hamilton website); will be communicated to all workers through Connection Bulletins and Memos to Supervisors/Managers; will be reviewed with Staff annually at CMT, DMT and cascaded out through Staff Meetings; will be referenced at all violence prevention training programs and shall be clearly referenced on all violence related notices/signs that are posted in conspicuous locations at each workplace. Each Department Management Team (DMT) is required to conduct a review of their “department violence in the workplace prevention procedure” annually, in consultation with the Joint Occupational Health and Safety Committee, and to revise it as necessary. Questions or concerns regarding the department procedure may be directed to the immediate supervisor or to a Wellness/Safety Specialist, representative of the Workplace Safety Section and any Labour Relations Officer. A list of designated staff along with telephone contact numbers and e-mail addresses is listed as Appendix F.

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A WORKPLACE VIOLENCE PROCEDURE QUICK REFERENCE SHEET, (attached as Appendix G) will assist all participants in applying this procedure. VII. INSTRUCTION TO SUPERVISORS/MANAGERS: Any supervisor, manager, or other person in authority who receives a report of a violation or alleged violation of this procedure, shall evaluate the suspected violation and shall consult with the Human Resources Labour Relations Officer and/or Safety Wellness Specialist and/or the Workplace Safety Section. Supervisors shall respond to any emergency situations related to violence in the workplace by contacting 911 and activating the department emergency response plan as may be necessary. Supervisors/Managers shall deal with all such issues brought to their attention with sensitivity, fairness, and impartiality. Privacy and confidentiality considerations shall be applied at all times when dealing with such issues. VIII. OTHER APPLICABLE POLICIES AND PROCEDURES: HARASSMENT AND DISCRIMINATION PREVENTION POLICY PERSONAL HARASSMENT PREVENTION POLICY HARASSMENT AND DISCRIMINATION COMPLAINT PROCEDURES VIOLENCE IN THE WORKPLACE PREVENTION POLICY WORKING ALONE PROCEDURE # COH-RQ-WI-006 IX. OVERVIEW – KEY ELEMENTS OF THE WORKPLACE VIOLENCE PREVENTION PROCEDURE: (attached as Appendix H) X. LIST OF APPENDICIES:

• “A” Violence Hazard Assessment Form – Violence in the Workplace Prevention • “B” Signs and Notices for Posting • “C” Required Contents of a department emergency action plan • “D” Critical Injury or Major Incident Report Form • “E” Report of Accidental Injury or Occupational Disease Form • “F” List of internal contacts • “G” Workplace Violence Prevention Procedure Quick Reference Sheet – Warning Signs/What to do and a blank list to record Emergency Phone Numbers • “H” Overview of Key elements of the Violence in the Workplace Prevention Procedure

NOTE: Workers and their supervisors shall be held accountable for violations of health and safety rules, regulations, and procedures. Disciplinary action, where necessary, will be dictated by the City of Hamilton disciplinary procedure and will be based on the merits of the specific case. Prior to disciplinary measures being taken, management is advised to consult with Labour Relations.

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APPENDIX A

Work Location: __________________ Address: _________________________________

INSTRUCTIONS

This form is designed to help management, workers and members of Joint Health and Safety Committees carry out an assessment of the potential risks of violence associated with the activities carried out in their Departments/Divisions/Work locations and to respond accordingly to any identified risks. Completion of this form supports the City of Hamilton’s effort to implement the Violence in the Workplace Prevention Procedure.

It is recommended that this form be filled out through a group effort involving a meeting between workers (the crew), the supervisor and a worker member of the Joint Health and Safety Committee.

The supervisor is to complete the form, co-sign with the worker member of the Joint Health and Safety Committee, in attendance, and process copies to the persons listed on the last page.

Should additional space be required for any of the question fields please attach additional comments.

PLEASE DO NOT USE PERSONAL INFORMATION OR REFERENCES WHEN DESCRIBING INCIDENTS!

Part 1: 1. Please describe your workplace and the types of activities carried out by employees at the location. ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ Part 2: (Please fill in the applicable circle) History: 2. Have there been incidents when employees at your work location experienced threats or have been threatened verbally or physically?

O No O Yes. (Please describe incidents and provide details such as: client on employee; employee on employee; employee on public, etc.) ___________________________________________________________________ ___________________________________________________________________

Hazard Assessment Form – Violence in the Workplace Prevention

Department/Division Hazard Assessment

Dept: _____________ Division: ___________ Section: ___________

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Part 3: (Please fill in the applicable circle/s) Activities which might expose employees to risk of violence: 3. Do employees at your work location work with money or other valuables? O No O Yes. Please provide details including # of employees: ________ List Specific Job Titles below: ___________________________________________________________________ ___________________________________________________________________ 4. Do employees at your work location deal with people who are under the influence of alcohol or drugs? O No O Yes. Please provide details including # of employees: ________

List Specific Job Titles below: ___________________________________________________________________ ___________________________________________________________________ 5. Do employees at your work location deal with people who regularly “act out”?

O No O Yes. Please provide details including # of employees: _________ List Specific Job Titles below: ___________________________________________________________________ ___________________________________________________________________ 6. Do employees at your work location monitor or regulate the activity of others or carry out processes or make decisions which adversely affect others?

O No O Yes. Please provide details including # of employees: _________ List Specific Job Titles below: ___________________________________________________________________ ___________________________________________________________________ 7. Are employees at your work location involved in projects or activities that may elicit a negative or confrontational response?

O No O Yes. Please provide details including # of employees: _________ List Specific Job Titles below: ___________________________________________________________________ ___________________________________________________________________ 8. Are there other aspects of the work at your work location that might spark a violent response?

O No O Yes. Please provide details. ___________________________________________________________________ ___________________________________________________________________

Part 4: (Please fill in the applicable circle) Working Alone (One factor which increases the risk of violence) Definition – A person works alone when s/he works in a situation where s/he is out of sight and out of hearing of another employee/s. (See City of Hamilton Working Alone Procedure # COH-RQ-WI-006)

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10. Does any person at your work location work alone during normal working hours? O No O Yes. Please provide details.

Specific Job Titles: ___________________________________________________________________ ___________________________________________________________________ 11. Does any person at your work location work alone after normal working hours?

O No O Yes. Please provide details including # of employees: ________ Specific Job Titles: ___________________________________________________________________ ___________________________________________________________________ 12. Please describe any precautions already taken to safeguard members at your work location who work alone. If to your knowledge there are currently no precautions in place to address violence related issues within your division, please fill in this circle: O Check the appropriate control currently in place within your division: O – Portable telephone; O -- walkie-talkie; O – personal alarms; O – buddy system; O – Other control/s, please provide details: ___________________________________________________________________ ___________________________________________________________________ Other factors which might increase risk of workplace violence 13. Please describe other factors at your work location or in your work activities which you feel might increase the risk of violence. ___________________________________________________________________ ___________________________________________________________________

Part 5: Reducing the risk of violence 14. Please describe policies or procedures already in place to reduce the risk of violence at your work location. (Attach copies if available.) ___________________________________________________________________ ___________________________________________________________________ 15. Please describe any related training programs currently or previously (within the past 2 years) provided at your work location. ___________________________________________________________________ ___________________________________________________________________ 16. In light of your responses to the questions in this assessment: (a) What further steps would you recommend to prevent violence in your work place? ___________________________________________________________________ ___________________________________________________________________ (b) What additional assistance do you feel you need to implement the above recommendations/controls? Please specify:

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___________________________________________________________________ ___________________________________________________________________ 17. Any additional comments you would like to make that which apply to your job/s that were not covered in any of the questions above: ___________________________________________________________________ ___________________________________________________________________

Date Assessment Completed: __________________________________ Completed by Supervisor: Worker JHSC Member: Print Name: ____________________________ Print Name: _______________________________ Signature: _____________________________ Signature: _______________________________ Work Phone #: _________________________ Work Phone #: _____________________________ Supervisor keeps original document for personal reference and forwards completed, signed copies of this “Violence Hazard Assessment Form” to: Joint Health and Safety Committee Co-Chairs; Applicable Union Office; Department Safety/Wellness Specialist if applicable and/or to the Workplace Safety Section;

Thank you for your co-operation and input.

This form is to be used for conducting the initial hazard assessment for violence in the workplace prevention at all work locations. Individual employee input is a key requirement in the successful implementation of this procedure. Joint Health and Safety Committees, based on the input provided from these questionnaires, will assess and make appropriate recommendations to management regarding the type (level) of training required within the Department/Division and any additional controls that may be required, to improve the goal of reducing violence related incidents through environmental design. The use of alternate forms is acceptable when special circumstances exist at a workplace. The alternate forms must be based on a recommendation from the Joint Health and Safety Committee and must have the approval of the Workplace Safety Section.

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APPENDIX B Post either Sign #1 or Sign #2

Sign #1 (both sections must be posted side by side)

Signs are to be posted in conspicuous locations at the workplace. These may be areas such as lunch rooms, reception areas, waiting rooms and similar.

Sign #2 on next page is a stand alone sign.

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APPENDIX C

A department emergency action plan should include, as a minimum:

• Procedures for calling for help;

• Procedures for calling for medical assistance;

• Procedures for notifying the proper authorities (security personnel and the police);

• Emergency escape procedures and routes, (could be the same as Fire Emergency Evacuation Plan);

• Safe places to escape inside and outside of the facility;

• Securing the work area where the incident took place;

• Procedures for accounting for all employees if a facility is evacuated, (may be the same as Fire Emergency Evacuation Plan);

• Identifying personnel who may be called upon to perform medical or rescue duties and;

• Training and educating employees in workplace violence issues and the emergency action plan. Other elements may include:

• Determining how to secure the workplace; • Establishing internal emergency numbers and/or code words to alert security or co-workers that

urgent help is required; • Identify the circumstances in which a command centre would be necessary and how it would be

set up; • Assign responsibilities for decision making and action to staff with the appropriate skills and

authority. Appoint alternates in case a key player is absent during the incident; • Provide clear guidelines to follow in various situations; • Provide the training necessary to respond to and defuse potentially violent situations; • Outline how supervisors are expected to respond to reported incidents of violence or harassment; • Identify scenarios where emergency services should be called and identify who is responsible for

contacting emergency services such as: -Security; -The Police’ -Emergency Response Personnel; -Victim Support Resources; -Other Outside Assistance.

• Identify scenarios where the work location would be “locked-down” (take refuge in a secure

location) or evacuated using the existing “fire emergency evacuation procedures”;

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• Rehears also, evacuation and lock-down procedures, or any other drills for specific situations likely to be encountered at the workplace;

• Provide a system to account for the safety of all personnel. May be the same as for “fire

emergency evacuation procedures”; • Set up procedures to:

-Provide immediate first-aid and medical help; -Deal with Emergency staff and Police;

-Complete medical and legal reports and forms. • Establish procedures for the sensitive management of communications regarding the incident

(e.g. informing members of the victim’s family, internal communications, media relations, etc.) The emergency response plan for each department workplace must consider any additional specific issues that may exist at a specific work place but which may not be covered in the list above.

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Page 1 of 4

City of Hamilton

City Hall, 71 Main Street West

Hamilton, Ontario,

Canada L8P 4Y5

APPENDIX D

THE CITY OF HAMILTON CRITICAL INJURY OR MAJOR INCIDENT INVESTIGATION REPORT

Check (√ ) the appropriate box: This "investigation report" is for use only for incidents involving City Staff.

О Critical Injury OR О Major Incident Report

(As defined under the Occupational Health and Safety Act -- (Major incident may include: Acts of Violence; Fire; Flood; Unconsciousness; fracture; amputations; threat to life Explosion; Trench Collapse; Electrical Contact; other.) Substantial loss of blood; loss of sight; major burns.)

*THE PURPOSE OF THIS FORM IS TO ASSIST INVESTIGATORS IN COMPLYING WITH SECTIONS 51 THROUGH 53 OF THE OCCUPATIONAL HEALTH AND SAFETY ACT. BY FOLLOWING THE SPECIFIC PATTERN OF QUESTIONS IN THIS FORM AND RECORDING PERTINENT INFORMATION THE ABOVE REQUIREMENTS WILL BE MET. *COMPLETION OF ADDITIONAL FORMS SUCH AS THE REPORT OF INJURY OR OCCUPATIONAL ILLNESS OR OTHER RISK MANAGEMENT/INSURANCE AND/OR VEHICLE ACCIDENT FORMS, AS MAY BE REQUIRED, IS ALSO MANDATORY.

SECTION 1 NOTIFICATION INFORMATION (How did you become aware of the incident/accident?) Date: ______________ Name of Caller: ________________________ Telephone No: ____________ Location of Caller: Date of Time of _______________________ Occurrence:_____________ Occurrence:___________ Incident/Accident Location: (if different) ___________________________________________________________________

SECTION 2 NOTIFICATION REQUIREMENTS

(List individuals or authorities you notified. The contacts marked by * are MANDATORY.) POSITION NAME PHONE NO. TIME NOTIFIED Emergency Units: __________________________ ______________ ________________

(Ex: "911" -- Fire; Police; Ambulance as may be necessary depending on needs of injured party.) Your Manager/Supervisor: _______________________ ______________ ________________

*Members JOHSC: ____________________________ ______________ ________________ (ex: Both Worker and Management Certified Members, where possible)

*MOL Inspector: __________________________ ______________ ________________ (required ONLY in case of - Critical Injury; Explosion; Electrical Contact; Trench Collapse)

*Corporate Workplace Safety Section or Department Safety Advisor: ______________ ________ ________________ Other: (Family; Training Division; Risk Management) ________________ ________ ________________

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CRITICAL INJURY OR MAJOR INCIDENT WORKSHEET Page 2 of 4

SECTION 3 INJURED/INVOLVED WORKER INFORMATION Name of Worker Injured/Involved: ________________________________________________________ Department & Actual Work Location: ______________________________________________________ Body Part Injured (specify head/neck etc): __________________________________________________ Type of Injury (specify burn/fracture etc): __________________________________________________ Briefly Describe how Injury Occurred: _____________________________________________________ _____________________________________________________________________________________

SECTION 4 OTHER PERSONS INVOLVED OR WITNESSES (Attach signed witness statements from names listed, along with personal contact information.)

Name Department/Work Location/Address Telephone No. ________________________ _______________________________ ______________ ________________________ _______________________________ ______________ ________________________ _______________________________ ______________ ________________________ _______________________________ ______________

PICTURE(S) OR DIAGRAM OF SCENE (Attach as separate sheet, if more space required.) List of Vehicles Involved or On Scene (if any): _________________________________________________ (Include vehicle # and/or license plate.) Hazardous Material Exposures (if any): _____________________________________________________ (Include name of substance and/or MSDS reference.)

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CRITICAL INJURY OR MAJOR INCIDENT WORKSHEET Page 3 of 4

SECTION 5 HOW DID THE CRITICAL INJURY OR INCIDENT OCCUR? (State exactly what happened according to your interpretation of the data acquired from visual inspection, witness statements, other input.) _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________

WHAT ACTS, FAILURES TO ACT OR CONDITIONS CONTRIBUTED TO THIS ACCIDENT? (Your impressions as the investigator.) _________________________________________________________________________________________ _________________________________________________________________________________________

WHAT WHERE THE BASIC OR FUNDAMENTAL REASONS FOR THESE ACTS OR CONDITIONS: (Your impressions as the investigator.) _________________________________________________________________________________________ _________________________________________________________________________________________

WHAT ARE YOUR RECOMMENDATIONS TO PREVENT RECURRENCE? (Check off (√) any steps already implemented.) ACTION: ACTION BY: COMPLETION DATE: О______________________________________________________________________________________ О______________________________________________________________________________________ О______________________________________________________________________________________ О______________________________________________________________________________________ О______________________________________________________________________________________ О______________________________________________________________________________________

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CRITICAL INJURY OR MAJOR INCIDENT WORKSHEET Page 4 of 4

SECTION 6 COMMENTS/NOTES (Provide any additional information, not included above, which may assist the investigation.) _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________

INVESTIGATION COMPLETED BY: (NOTE: THIS REPORT/INVESTIGATION MAY BE CONDUCTED INDIVIDUALLY OR JOINTLY BY MANAGEMENT AND WORKER/S' REPRESENTATIVES. ONLY THE PERSON/S COMPLETING THE REPORT IS/ARE REQUIRED TO SIGN BELOW.)

___________________________________ ___________________________________ Supervisor OR Management JHSC Rep (please print) Signature ___________________________________ ___________________________________ Work Location Telephone No. ____ _______________________________ ___________________________________ Worker JHSC Rep (please print) Signature ___________________________________ ___________________________________ Work Location Telephone No.

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APPENDIX E

REPORT OF ACCIDENTAL INJURY AND OCCUPATIONAL DISEASE Fax to Human Resources (905 546 4174) WITHIN 24 Hours

A Department Name:

Section Name: Work Location Department ID:

Employee Identification Surname: Given Names: Employee ID: Empl Record #:

(if applies) SIN#:

Address: Apt #: Job title at time of injury/awareness of disease: Yrs Experience in job:

City: Province Date of Birth (mm/dd/yy) Male Female Hire Date (mm/dd/yy)

B

Postal Code: Telephone # (Include Area Code): Worker’s Preferred Language of service English French Other Language:_________________

C TEMPORARY DISABILITY Following the day that the injury/awareness of disease occurred, will the injured worker be absent from work because of the injury/disease? Unknown Yes No If you answered “No” to the above, will the injured worker as a result of the injury/disease:

• Assume other work duties because the injury/disease prevents him/her from performing his/her regular duties? Yes No • Earn less than his/her regular wages because of the injury/disease? Yes No

Note: If you answered No to all of these questions do not complete Section F “Earnings Information” Accident/Illness Dates and Details (Part 1)

Date of accident: (mm/dd/yy) Time of accident: Am Pm

Who was the Accident/Illness reported to? Name: Position: Date reported (mm/dd/yy) Time reported: Am

Pm Telephone # (Include extension): Was the Accident/Illness: (check all that apply)

Sudden specific event / occurrence Gradually occurring over time Occupational disease Critical (add’l report required) Fatality

Type of Accident/Illness: (please check all that apply) Struck/Caught Fall Slip/Trip Overexertion Harmful substances/environment Motor Vehicle Incident Repetition Assault Vehicle # __________ Fire/Explosion Other : ______________________________________

Area of Injury (Body Part) – Please check all that apply Head Teeth Upper Back Face Neck Lower Back Eye(s) Chest Abdomen Ear(s) Pelvis Other:_____________________

Left Right Shoulder Arm Elbow Forearm

Left Right Wrist Hand Finger(s)

Left Right Hip Thigh Knee Lower Leg

Left Right Ankle Foot Toe(s)

D

Describe what happened to cause the accident/illness and what the worker was doing at the time (lifting a 50 lb box on wet floor, repetitive movements etc.). Include what the injury is (strain, cut, pain, etc.) and any details of equipment, materials, environmental conditions (work area, temperature, noise, fumes, other person, etc.) that may have contributed. For a condition that occurred gradually over time, describe the physical activity required to do the work.

E

Remedy (As a supervisor, what action have you taken or do you propose to take to prevent a repeat of this incident?) Include a proposed timeline to complete the action. Attach a list if more space is required. Important – Mark completed items with a

Earnings Information- Do not complete this section if you answered “No” to all the questions in Section C Employees Work Schedule: S:

Indicate days off if not Sat/Sun: Week 1 Mon Tues Wed Thur Fri

Week 2 Mon Tues Wed Thur Fri

R: Define 2 week work schedule starting with week of absence start (indicate hours worked per day and “X” days off)

F

Other: Mon Tues Wed Thur Fri Sat Sun

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Week 1 Week 2

If worker worked after the first absence, please enter dates:

From: (mm/dd/yy)

HH:MM Am Pm

To: (mm/dd/yy)

HH:MM Am Pm

Employee Name: Employee Number: Health Care Did the worker receive health care for this injury? Yes No

If yes, when? (mm/dd/yy) _______________________ When did you learn the worker received health care? (mm/dd/yy) _______________________ Where was the worker treated for this injury? Please check all that apply:

Ambulance Emergency Department Admitted to Hospital Health Professionals Office Other:_______________________ Name, address and phone number of health professional or facility that treated this worker? (if known):

Accident / Illness Dates and Detail (Part 2) Did the accident/illness happen on the employer’s premises

(owned, leased or maintained)? Yes No

Specify where (office, shop floor, yard, client/customer site, parking lot, etc.)

Did the accident/illness happen outside the Province of Ontario? Yes No

If yes, where (City, Province/State, Country)

Are you aware of witnesses or other employees involved in this accident/illness?

Yes No

If yes, please provide employee #, name, and work extension: 1) ________________________________________________________ 2) ________________________________________________________

Was any individual who is not an employee partially or totally responsible for this accident/illness?

Yes No

If yes, please provide name and work phone number

Are you aware of any prior similar or related problem, injury or condition? Yes No

If yes, please explain. If it was work related, see below.

If you have concerns about this claim, attach a written submission to this form. submission attached

Recurrence of Previous Accidental Injury or Occupation Disease Is this report of Accidental Injury or Occupational Disease a recurrence of a previous accidental injury or occupational disease? Yes No

If yes, enter date of original injury and Claim Number if known. Date (mm/dd/yy) Claim Number Was there another accident that caused the recurrence? Yes No

If yes, describe on this report

Has the employee been carrying out his/her regular duties between returning to work after the first day off and the date of recurrence? Yes No If No, please describe:

After first report of Accident injury or Occupation Disease, has the employee complained to his/her supervisor or other workers of any problems resulting from that Accidental injury or Occupational Disease since returning to work? Yes No If yes, please describe and provide names.

Return to Work Have you been provided with work

limitations for this worker’s injury? Yes No

Has modified work been discussed with this worker?

Yes No

Has modified work been offered to this worker?

Yes No

If yes, was it Accepted Declined

Supervisor Identification It is an offence to deliberately make false statements to the WSIB. I declare that the above information is accurate, to the best of my knowledge. Supervisor at the

time of Accident/Injury: Job Title: Employee ID: Empl Record#

(if applies) Signature of Supervisor:

Work Telephone ext. #: Work Cell #:

Date (mm/dd/yy)

Employee’s Supervisor, if different than above Job Title: Employee ID:

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APPENDIX F Department Labour Relations Department Safety/Wellness Officer: Specialist: - Wanda Herriott, ext 6668 - Val Sarjeant, ext 2396wherriot@hamilton.ca vsarjean@hamilton.ca - Flavia Tranquilli-Nardini, ext 4294 - John Serafini, ext 2392ftranqui@hamilton.ca jserafin@hamilton.ca - Andre Gulabsingh, ext 4464 - Liz Sisolak, ext 5539 agulabsi@hamilton.ca lsisolak@hamilton.ca - Ryan Fletcher, ext 4031 - Les Fenyvesi, ext 4176 rfletcher@hamilton.ca lfenyvesi@hamilton.ca HR Department (for Employee Family Assistance Program): - Gail Stevely, ext 4265 gstevely@hamilton.ca - Bronwyn Ott, ext 7141 bott@hamilton.ca HR Department (for Critical Incident Peer Response Team): - Leslie Croft, ext 2642 lcroft@hamilton.ca - Alternate: Joe Xamin, ext 6667 jxamin@hamilton.ca

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APPENDIX G

WORKPLACE VIOLENCE PROCEDURE QUICK REFERENCE SHEET: Warning Signs of a potentially violent person:

• Verbal, nonverbal, or written threats or intimidation, explicit or subtle

• Fascination with weaponry and/or acts of violence

• Expression of a plan to hurt self/others

• Feelings of persecution, expressed distrust, especially with management

• Fear reaction to employee among coworkers/clients

• Frequent interpersonal conflicts

• Displays of unwarranted anger

• Indications of marked mood swings

• Violence toward inanimate objects

• Sabotaging projects or equipment

• Holding a grudge against a specific person; verbalizing a hope that something will happen to him/her

What to do if there is an incident:

Employee: • If an emergency, or if you suspect criminal conduct, call your immediate supervisor OR

911 - City of Hamilton Police Department immediately.

• Notify immediate Supervisor and follow department emergency plan as directed.

• If not an emergency, inform your immediate supervisor of the incident.

Managers and Supervisors: • If an emergency, or if you suspect criminal conduct, call 911 - the City of Hamilton Police

Department immediately.

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• Follow department emergency plan as may be necessary. • If not an emergency, contact a member of the Human Resources Labour Relations

Division, as appropriate, for advice and direction. Conduct investigation as may be directed.

What to do following an incident:

Managers and Supervisors: • Contact Human Resources Benefits/Wellness Section, to activate EFAP, if appropriate, for

initial debriefing and assessment. • Contact Critical Incident Peer Response Team (if applicable) as may be required.

• Contact Department Safety/Wellness Advisor or the Workplace Safety Section.

Emergency Phone Numbers

Please fill in the “Emergency Phone Numbers” appropriate for your building. Copy this box and tape on your desk by your phone or somewhere else close to your phone for handy reference. (Copies of this card also can be made.) Immediate Supervisor: __________________________________________________ Building Security/Front Desk: _____________________________________________ Police Emergency: 911 Fire Department: _______________________________________________________ Ambulance: ___________________________________________________________ Health Unit: ___________________________________________________________ Joint Health and Safety Committee Member: _________________________________ Department Labour Relations Advisor: ______________________________________ Department Workplace Safety/Wellness Advisor: ______________________________ Employee/Family Assistance Program: ______________________________________

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APPENDIX H

Overview of Key elements of the VIOLENCE IN THE WORKPLACE PREVENTION PROCEDURE

Purpose of Procedure: To discourage and prevent acts of violence in the workplace before they occur. To outline proper/recommended measures to take in the event acts of violence occur in spite of all reasonable effort to prevent them and the measures that can be taken to support employees who are affected by such violence. Responsibilities outlined in the Procedure: Departments are responsible for implementing this procedure and for establishing specific programs to prevent incidents of violence in the workplace. Mandatory “Violence in the Workplace Prevention Procedure” Components: (Each is defined in detail in the Procedure)

• Completion of a Violence Prevention Hazard Assessment in consultation with local JHSC.

• Posting and Distribution of Violence in the Workplace Prevention Policy statement and this Procedure.

• Posting Zero Tolerance for Violence Signs in conspicuous locations. • Developing an Emergency Response Protocol to respond to acts of violence at each work

location. • Provide information and training to all City employees in Violence Prevention Program

Components appropriate to the employee’s degree of exposure as determined by the hazard assessment.

• Process for reporting and investigating occurrences. • Provision of EFAP and similar support services to employees affected by occurrences of violence.