Personal Safety Incident Report

Fields marked with an * are required

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The purpose of this form is to collect background data to help MAHCP push for meaningful, effective change aimed at reducing personal injury, minimizing threats and ensuring appropriate support for our members. Please complete ONE form per incident so we can track incidents accurately.

We remind you that any information you provide us is confidential and will be treated as background information for research purposes only. MAHCP will only share results in the form of anonymous, collated data and responses will never be attributed to an individual. Please be advised that your MAHCP Labour Relations Officer may reach out to you to discuss your report. Thank you for sharing with us.

First Name *

Last Name

Personal email *

Job title

Worksite

Zone or department *

Approximate date of incident *

Approximate time of incident

Location of incident *

Incident type

Threatening behaviour – such as shaking fists, destroying property or throwing objects.
Verbal or written threats – any expression of an intent to inflict harm.
Verbal abuse – swearing, insults or condescending language.
Physical attack – hitting, shoving, pushing or kicking.

Weapons involvement *

Incident description

500 of 500 Character(s) left

Security or law enforcement involvement

Report to employer

Level of employer support

Report to WCB

Final comments

500 of 500 Character(s) left

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