Incident intake form | Environmental health and safety

Incident Report Form

This form can be completed for any incident or near miss that involves a member of our UM community (employees, students and visitors).

UM employees must first report their incident to their supervisor.

You can review the Incident Reporting Procedure (located on the Workplace Safety and Health page on the UM Intranet) for direction on reporting an incident. Log into the UM Intranet to learn more.

If this is an urgent matter, call the Environmental Health and Safety Office immediately for assistance at 204-474-6633 or contact UM Security Services outside of normal business hours.

Information for the person completing the form

Full name

Position (if applicable)

Contact number

Information for the individual involved

Name of individual involved

Email of individual

A copy of this form will be sent to your email address.

Contact number for individual involved

Name of their supervisor (if applicable)

Email of supervisor (if applicable)

A copy of this form will be sent to your supervisor.

Date supervisor (or U of M) was informed

Incident description

Type of incident

Injury

Occupational illness

Chemical

Fire

Flood

Motor vehicle accident

Property damage

Equipment failure

Other

Date of incident

Time of incident

Location

Include the building name, room number and a description of the area.

Description of the incident

Describe what happened during the incident, the surroundings, what activities occurred during the time of the incident, contributing factors, etc.

Immediate corrective actions taken

Indicate any action taken to mitigate any possible injury or further incident.

Did anyone witness this incident?

Yes

Full name

Position

Contact number

Have you seen or do you intend to see a healthcare provider?

Examples of healthcare providers include doctors, chiropractors, nurses, physiotherapists, etc.

Yes

Notice Regarding Collection, Use, and Disclosure of Personal Information and Personal Health Information by the University

Your personal information and personal health information is being collected under the authority of The University of Manitoba Act. The information you provide will be used by the University to track all injuries that occur at the University, to determine if a Workers Compensation Board claim is required, and for communication. Your personal information and personal health information may be disclosed to the Worker’s Compensation Board in the event of a WCB claim.

Your personal information and personal health information will not be used or disclosed for other purposes, unless permitted by The Personal Health Information Act (PHIA) or The Freedom of Information and Protection of Privacy Act (FIPPA). If you have any questions about the collection of your personal information or personal health information, contact the Access & Privacy Office (tel. 204-474-9462), 233 Elizabeth Dafoe Library, University of Manitoba, Winnipeg, MB, R3T 2N2.

Acknowledgement

Environmental health and safety

University of Manitoba