Manitoba incident report template

Set up for Manitoba

• A serious incident is one in which a worker is killed or suffers an injury from electrical contact, unconsciousness from a concussion, a fracture of the skull, spine, pelvis, arm, leg, hand or foot, an amputation of an arm, leg, hand, foot, finger or toe, third-degree burns, permanent or temporary loss of sight, a cut or laceration needing medical treatment at a hospital, or asphyxiation or poisoning; or one involving a structural collapse or failure (building, structure, crane, hoist, lift, temporary support or excavation), an explosion, fire or flood, an uncontrolled spill or escape of a hazardous substance, or the failure of an atmosphere-supplying respiratorM.R. 217/2006, s. 2.6
• As soon as reasonably practicable, the employer has each serious incident investigated, as well as any accident or dangerous occurrence that injures a person who then needs medical treatment or that could have caused a serious incident; the investigation is done by the committee co-chairpersons or their designates, or the employer and the workplace representative, or, where there is neither, the employer with a worker not associated with managementM.R. 217/2006, s. 2.9 (1), (2)

Also required in Manitoba

These rules are about how and when you report, not the template's fields. Check them before you deliver.

• When a serious incident occurs, the employer notifies the Workplace Safety and Health Branch immediately by the fastest means available, giving the name and address of each person involved, of the employer (and of any other employer of a person involved), and of each witness, the date, time and location, and the apparent cause and circumstances; inaccurate or incomplete information is corrected immediatelyWorkplace Safety and Health Regulation, M.R. 217/2006, s. 2.7
• Except to free a trapped person or avoid an additional hazard, and subject to a safety and health officer's directive, nothing involved in a serious incident is altered or moved until at least 24 hours after the notice to the branchM.R. 217/2006, s. 2.8
• After the investigation, the employer, consulting the co-chairpersons, representative or worker, prepares a written report with the name of anyone injured or killed; the date, time and place; a description; any graphics, photographs or other evidence that may help determine the cause; an explanation of the cause, including factors or events that indirectly contributed; any immediate corrective action taken; and any long-term action to prevent a similar occurrence, or the reasons for no actionM.R. 217/2006, s. 2.9 (3)
• Records required by the regulation are kept for the period it prescribes or, where none is prescribed, for five years after they are made or come into the employer's possessionM.R. 217/2006, s. 2.10
• Every workplace safety and health program includes a procedure for investigating incidents and dangerous occurrences and a procedure for worker participation in their investigationThe Workplace Safety and Health Act, C.C.S.M. c. W210, s. 7.4 (5) (i), (j)

What is in it

• What happenedWhat the person was doing just before the incident, with the tools, equipment or material used, then how the incident happened, in the order it happened.
• Injury or illness and treatmentThe part of the body affected and how, the object or substance that directly caused harm, and the first aid or medical treatment given and where.
• Damage to property, equipment or the environmentWhat was damaged, spilled or released, and how much, as the notes give it.
• Immediate actions takenWhat was done right away: first aid, emergency calls, the area made safe, equipment stopped or tagged out, and who was notified.
• CausesThe immediate cause and any underlying causes the notes identify: equipment, procedures, training, work conditions, supervision. Only what the notes support.
• Witness statementsName, Role, What they saw or said
• Corrective actionsAction, Responsible, Due, Status

Rules last reviewed October 12, 2026. Read the full Manitoba incident report requirements.