Work Related Injury / Near Miss Report

Frequently Asked Questions

Serious Injuries / Incidents

Serious injuries / incidents must be reported to your manager immediately and they must contact the Manitoba Workplace Safety and Health Branch at:

• Winnipeg: 204-957-SAFE (7223)
• Toll-free: 1-855-957-SAFE (7233)

A Serious Injury / Incident is defined 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.

To be completed by affected employee.

Work Related Injury / Near Miss Report

"*" indicates required fields

Step 1 of 6

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1. EMPLOYEE PERSONAL INFORMATION

Employee name*

First Last

Employee ID*

Home / Cell phone*

Employee email*

DoB (dd-mm-yyyy)

DD dash MM dash YYYY

Gender

Female

Male

Other

Job title*

Site*

(please choose)Aikins 601Bannatyne 817Booth 280 (Access Winnipeg West)Breast Health CentreBroadway 280Broadway 705 – Nine Circles CHCCadham LabsCarlton 300CH – WRHA CorporateChurchillConcordia 1155 (HKI)Concordia HospitalConcordia PlaceCorporate-OtherDeer Lodge CentreDLC – WRHA CorporateElgin 425GH – WRHA CorporateGolden WestGoulet 170 (Access St. Boniface)Grace HospitalHargrave 490Hargrave 496Henderson 975 (Access River East)HSCHSC – WRHA CorporateKeewatin 785 (Access Norwest)Laundry – InksterLaundry – SelkirkLeila 1050MacGregor 363Magnus 146Main 640 (Access Downtown)Main 650Main 886 (Mount Carmel Clinic)McPhillips 2300MHCMHC – WRHA CorporateMiddlechurchNotre Dame 1155Pan Am ClinicPlaza 135 (Access Fort Garry)Portage 1031Portage 1041Portage 323Portage 355Portage 698Portage 755Regent 845 (Access Transcona)Regional Distribution FacilityRHC – WRHA CorporateRiver Park GardensRoblin 3401SBGH – WRHA CorporateSelkirk Mental Health CentreSeven Oaks General HospitalShared HealthSherbrook 790 (MB Clinic)SOGH – WRHA CorporateSt. Boniface HospitalSt. Mary's Road 603Sutherland 80Tissue Bank – Dugald 1337UnspecifiedVGH – WRHA CorporateVictoria General Hospital

Program*

(please choose)

Department*

(please choose)

Job status

Full Time

Part Time

Casual

Employee's EFT

Employee's union*

(please choose)CUPEMAHCPMGEUMGEU – TPMNUNon-Union

MAHCP opt out declaration

MAHCP Members:
As per your collective agreement, a summary of this INM will be provided to MAHCP. You may opt out of sharing your name by selecting “No” below.

No

MNU opt out declaration

Manitoba Nurses Union Members:
As per your collective agreement, a summary of this INM will be provided to MNU. You may opt out of sharing your name by selecting “No” below.

No

2. MANAGER / SUPERVISOR DIRECT REPORT

Manager's / Supervisor's name*

First Last

Manager's / Supervisor's phone

Manager's / Supervisor's email

Community team manager name

First Last

(if applicable)

3. INCIDENT INFORMATION

Incident date (dd-mm-yyyy)*

DD dash MM dash YYYY

Incident time

Hours

:

Minutes

AM PM AM/PM

Date reported (dd-mm-yyyy)*

DD dash MM dash YYYY

Reported to*

First Last

Job title*

Were there any witnesses to the injury / near miss?*

Yes

No

Unknown

Reporting type*

(choose all that apply)

First Aid

Medical Aid (Healthcare Provider)

Report Only

Time Loss

Name(s) of witness(es)*

First

Last

 

Add Remove

4. LOCATION OF INCIDENT

Incident location*

(choose all that apply)

Client’s address

Site exterior

Site interior

Other

Other incident location

Site interior details

Building name*

Floor / Unit*

Room / Area*

Site exterior details

Exterior location*

Client's address detail

Address

Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code

5. EMPLOYEE DESCRIPTION OF INCIDENT

Incident description*

Is this a physical injury?*

Yes

No

REGION OF BODY INJURED*

Body region

Body side

 

(please choose)No physical injuryAbdomenAnkleArm, LowerArm, UpperBack, LowerBack, MidBack, UpperChestEarElbowEyeFaceFingers / NailsFootHandHead / HearingHipKneeLeg, LowerLeg, UpperMouth / TeethNeckNosePelvis / GroinShoulderToes / NailsWrist

(please choose)RightLeftBoth (right and left)

Add Remove

(select all that apply)

To request more than one item above, please use the to the right of the row of fields.

Other body region and side

Type of injury / exposure*

(check all that apply)

Allergic Reaction

Amputation

Animal Bite / Scratch

Asphyxiation

Insect Bite

Blood and Body Fluid Spill / Splash

Bruise / Crush / Abrasion

Burn / Scald

Chemical Exposure

Collapse of Building or Structure

Concussion

Cut / Laceration / Puncture (Minor)

Cut / Laceration / Puncture (req. Hospital treatment)

Death

Dermatitis / Rash

Dislocation

Electrical Contact

Explosion

Exposure to Cold / Heat

Eyesight Loss

Fainting

Fire

Flood

Foreign Object

Fracture

Hazardous Spill

Hearing Loss

Human Bite / Scratch

Illness – Not Work Related

Illness – Work Related

Infection / Infestation

Internal Injury

Loss of Consciousness (due to concussion)

Needlestick

Pain

Pain – No Incident

Paralysis

Physical Reaction

Poisoning

Psychological Injury

Sprain / Strain

Third Degree Burn

No Injury

Other

Other type of injury / exposure

This is a serious incident!
Please notify your manager/supervisor immediately. Serious injuries must be reported to the Provincial Office of Manitoba Labour Workplace Safety and Health Division at: 204-945-3446 (regular working hours) or 204-945-0581 (after working hours).

Form completed by*

First Last

Signature*

Comments

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