Government of Ontario

Office of the Chief Coroner

Case Selection Data Form

Please complete all fields

Coroner Last Name
Coroner First Name
Date Call Received (yyyy/mm/dd)
Time Call Received
Caller Last Name
Caller First Name
Caller Position
Telephone No. (incl. area code)
Deceased Last Name
Deceased First Name
Date of Birth (yyyy/mm/dd)
Date of Death (yyyy/mm/dd)

Place of Death (Address)

Unit No.
Street No.
Street Name
PO Box
City/Town
Province
Postal Code

Brief Circumstances of Death/Action Plan

1. Was the death all natural?
i.e. was the death entirely due to natural causes without
contribution from a non-natural condition or event

Yes No

2. Was the death reasonably foreseeable and does the cause
flow logically from a natural disease process?

Yes No

3. Is there a designated health care practitioner to complete the
Medical Certificate of Death?

Yes No

4. Is the case free of significant care related concerns from either
family or care providers?

Yes No

5. Are OCC policy and/or Section 10 (2)(3) statutory obligations
excluded?

Includes:
• Child with CAS involvement (direct service in the past 12 months);
• Threshold case for a long term care facility;
• Decomposed body;
• Need for positive identification;
• Deaths in:
a) Charitable institutions
b) Children’s residence under the Child & Family Services Act
c) A supported group living residence under the Services and Supports to Promote the Social Inclusion of Persons with Developmental Disabilities Act
d) A psychiatric facility under the Mental Health Act
e) An institution under the Mental Hospitals Act
f) A public or private hospital to which the person was transferred from a facility, institution or home referred to in a) to e) above.
Yes No

Accepted for a Death Investigation? (Criteria – answer “No” to any of questions #1-5, and/or careful consideration of Section 10 criteria)

Declined for Investigation? If yes, inclusion criteria for reporting and payment met?
Electronically submit Case Selection Data Form & Case Selection Invoice to the Regional Supervising Coroner’s Office via Enterprise A ttachment Transfer Service (EATS) or via Fax if EATS is unavailable for payment.