Notification of Death or Serious Bodily Harm

Agency Information

Name of Reporting Agency *

Address of Reporting Agency *

Phone Number of Reporting Agency (###-###-####) *

Name of Placing Children's Aid Society/Involved Children's Aid Society *

Name of Children's Aid Society Investigating (If applicable)

Date of Incident (yyyy-mm-dd) *

Time of Incident (hh:mm AM/PM) *

This Notification Pertains To: *

Information Regarding Child/Youth and Incident

Attention: Please do not include the name of child/youth associated with this notification

Age on Date of Incident *

Location of Incident (city, town) *

Province *

Specific Location *

Was the child in the care of the CAS at time of incident? *

Home Community (please enter unknown if you do not know) *

Province *

Postal Code (A9A 9A9)

Please describe the circumstances (What, where, and when it happened, actions taken by the Service Agency) *

Additional Notes (For any additional information in regards to reporting and notification)

Submitted By

First Name *

Last Name *

Organization Email *

Contact person for further information

First Name *

Last Name *

Date of Notification Submission (yyyy-mm-dd) *

Notification Requirements

Attention:

You are asked to provide the necessary contact information for the Office of the Ombudsman as soon as possible and at least within 14 days of the Incident.

Service providers should maintain records that document that they have complied with the obligation to notify children, parents and others about the Ombudsman's Office, as required, as the Ombudsman may request this confirmation at a later date as part of an individual or systemic investigation.

* These fields are required.

*Please print the form for your own records before submitting. A copy of the completed form will not be provided following submission.

You will receive a confirmation email once you have submitted the form.