Incident Reporting | Brandon University

Company

This field is for validation purposes and should be left unchanged.

This form to be completed after an incident, after injured people have been appropriately attended to, first aid has been delivered by trained personnel, and after a scene has been made secure. For immediate assistance in an emergency, where these is immediate risk of harm to people or property, please contact 911, Campus Security, or the nearest Unit/Faculty Office.

Incident Report Number

Name*

First Last

Contact info*

Please provide a phone number or email address. If you would like a copy of this form entry sent to you, this must be your Brandon University email address.

CC Me

Would you like a copy of the completed form sent to your email?

Please email me a copy of the completed form.

Statement*

Please describe the incident or hazard/near miss.

Loss Incurred

Description

Describe the loss incurred. Includes but not limited to damaged or destroyed equipment, damaged property, personal property, stolen property, wage loss, time loss, missed time.

Type of Occurrence

Type of Occurrence*

Other Occurrence Type*

Definition of Serious Incident

The Workplace Safety and Health Regulation defines a serious incident as one:

in which a worker is killed;
in which a worker suffers
- an injury resulting from electrical contact,
- unconsciousness as the result of a concussion,
- a fracture of his or her skull, spine, pelvis, arm, leg, hand or foot,
- amputation of an arm, leg, hand, foot, finger or toe,
- third degree burns,
- permanent or temporary loss of sight,
- a cut or laceration that requires medical treatment at a hospital as defined in The Health Services Insurance Act, or
- asphyxiation or poisoning; or
that involves
- the collapse or structural failure of a building, structure, crane, hoist, lift, temporary support system or excavation,
- an explosion, fire or flood, an uncontrolled spill or escape of a hazardous substance, or
- the failure of an atmosphere-supplying respirator.

Serious incidents must be reported to provincial authorities and the scene must be secured for a minimum of 24 hours.

For more information, see the relevant Government of Manitoba webpage.

Note

Serious incidents must be reported to provincial authorities and the scene must be secured for a minimum of 24 hours.

Loss incurred by

How is the person/people affected affiliated with Brandon University?

Brandon University
Student
Employee
Contractor
Public
Other

Other:

Manager's Email Address*

Incidents involving employees must be reported to the applicable unit head.

Date of Incident*

Time of Incident*

:

Injury Report

Row ID	Name of Injured Person	Actions

There are no Injuries.

Spill Report

Row ID	Date of spill	Location	Actions

There are no Spills.

Location of Incident*

Date Reported*

Time Reported*

:

Reported To*

Reported By*

Working Conditions

Work Schedule

# of Days On*

# of Days Off*

# of Hours/Day*

Number of Hours Worked

That day

Previous day

That shift

Did the incident occur indoors or outdoors?*

If the incident took place outdoors, please fill in the Weather Conditions section.

Indoors
Outdoors

Weather Conditions

Temperature

Approximate temperature in degrees Celsius

Please enter a number from -60 to 60.

Sky

Sky conditions: cloudy, clear, partly cloudy, night, etc.

Precipitation

Approximate amount and type of precipitation. eg. "5mm rain", "35cm snow", "none".

Wind

Approximate wind speed and direction.

Ground/road conditions

eg. "clean and dry", "icy", "wet"

Comments

Please add any other comments you might have about the working conditions.

Photos

Photos are helpful in any incident or hazard investigation. Please attach any photos of the scene.

I have relevant photo(s) to attach

Upload images/diagrams

Upload up to 10 images or diagrams

Drop files here or

Accepted file types: jpg, png, gif, Max. file size: 64 MB, Max. files: 10.

Witnesses

Please list any witnesses to the incident.

Name	Actions

There are no Witnesses.

Witness Statement(s)

I have witness statement(s) to attach

Witness Statements

Name	Actions

There are no Statements.