This sample template is provided as a resource, for the consideration of each school board in developing their own form. Each school board is responsible for ensuring that the version of the form they use, and their procedures around the form, are compliant with their responsibilities under the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA ), OHSA , and other legislation.
Sample template Do not post
Notification of potential risk of physical injury (general safety plan) [Insert school board name and logo]
This form is intended to facilitate the school board’s duty under s.32.0.5 (3) of the Occupational Health and Safety Act to provide information to workers related to a risk of workplace violence from a person with a history of violent behaviour. This form must be completed by a principal or vice principal and provided to a worker at school if: a) the worker can be expected to encounter that person in the course of his or her work; and b) the risk of workplace violence is likely to expose the worker to physical injury.
Section A: Board policy and procedure [Insert hyperlink to Board Policy and Procedure]
[Insert School or Work location]
Section B: How to summon immediate assistance [Insert information as to how to summon immediate assistance]
Section C: Identifying information of the individual presenting risk [Insert the person’s name, if known.]
[Insert additional information (description).]
Section D: Description of reported concerns [Insert a description of the concerns reported about the individual and the risk of physical injury.]
Section E: Preventative measures put into place [Insert what preventative measures are in place to prevent risk of physical injury.]
Section F: Safety strategies if encountering the individual Do take the following action [Insert what a person should do when in contact with the individual.]
Do not take the following action [Insert what a person should not do when in contact with the individual.]
Completed by[insert name]
Retain in a central and secure location
