MSBA - Incident Report Form
Language
  • English (Canada)
  • French (Canada)
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  • MSBA: Incident Report Form

    This form is only for reporting incidents and must be completed by a division employee. Please do not submit claims details through this form.
  •  -
  • Please select the type of incident to report:*

  • Student Accident Incident Report

  • For student claims submissions, please download the claims form below:

    English Claims Form
    French Claims Form

    For more information on student claims, visit the MSBA School Insurance Program Page

  • Date of Birth of Injured Person*
     - -
  •  -
  • Date of accident*
     - -
  •  :
  • Was the injury the result of a vehicular accident or incident?*
  • Was this a violent related issue?*
  • Was this violent related issue intended or unintended?
  • Guidelines on classification of accident/injuries*
  • Nature of Injury*

  • Type of Injury (body part)*

  • Where on the body*
  • Was the injury treated?*

  • Was a teacher/supervisor present or providing supervision?*
  • Pupil was:*
  • Was parent notified:*
  • Has there been any subsequent contact with the parents?*

  • Non-Student Accident Incident Report

  • Date of Birth of Injured Person*
     - -
  •  -
  • Date of accident*
     - -
  •  :
  • Was the injury the result of a vehicular accident or incident?*
  • Was this a violent related issue?*
  • Was this violent related issue intended or unintended?
  • Guidelines on classification of accident/injuries*
  • Nature of Injury*

  • Type of Injury (body part)*

  • Where on the body*
  • Was the injury treated?*

  • Employee Accident Incident Report

  • For Staff Occupational Accident claims submissions, please download the claims form below:

    English Claims Form
    French Claims Form

    For more information on The Staff Occupational Accident Plan, visit the MSBA School Insurance Program Page

  • Date of Birth of Injured Person*
     - -
  •  -
  • Date of accident*
     - -
  •  :
  • Was the injury the result of a vehicular accident or incident?*
  • Was this a violent related issue?*
  • Was this violent related issue intended or unintended?
  • Guidelines on classification of accident/injuries*
  • Nature of Injury*

  • Type of Injury (body part)*

  • Where on the body*
  • Was the injury treated?*

  • Date of Submission*
     - -

  • Note: Only school division authorized email addresses are valid.

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  • Please note: the information submitted on this form will be used solely for the purpose of claim investigation.

  • Should be Empty: