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.
 

Emergency disclaimer

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

Information for the individual involved

Identification

Incident description

Type of incident
Include the building name, room number and a description of the area.
Describe what happened during the incident, the surroundings, what activities occurred during the time of the incident, contributing factors, etc.
Indicate any action taken to mitigate any possible injury or further incident.
Did anyone witness this incident?

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

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