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Incident/Accident Report
All reports will be reviewed with one (1) buisness day.
Type of Report
Choose an option
Who is submitting this report?
First Name
Last Name
Job Title
Email
Person involved in accident/near miss/incident:
First Name
Last Name
Nature of the event:
Did an injury occur?
*
Yes
No
Medical treatment required?
*
Yes
No
Name of facility, hospital or physician:
If yes, what type?
First Aid (On-site)
Urgent Care (Promt Care)
St. Michael Hospital/ED
Body part(s) affected:
Describe Event or Incident
Please describe the event:
Identify the factors that you believe contributed to or caused the incident:
I declare that the info I’ve provided is accurate & complete
Initials
Submit
Report Submitted
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