Report summary

  • Report Title

  • Report Conducted on

  • Report Prepared by

  • Location
  • Weather Conditions

Incident detail

  • Time incident occurred

Type of Incident

  • undefined

Incident Description

  • Describe how incident occurred

  • Describe who is impacted, will this impact across UMMS?

Actions undertaken to resolve Incident

  • Describe UMMS rectification actions (if applicable)

  • Person(s) notified via escalation process

Incident Location ( building, floor, room number)

  • Describe where incident occurred

  • Google map & GPS location
  • Check box if incident occurred within a building

  • Building Name

  • Floor

  • Room number

  • Images of incident location ( only as needed )

Personnel Responding


  • Person
  • Name

  • Person
  • Name

  • Emergency Services? (Baltimore City, Baltimore County, Anne Arundel County, Howard County)

  • Fire

  • Police

  • Ambulance Service

  • State Emergency Service

  • Other Respondants (including contractors)?

  • Safety Authority (including ORS inspector, Health inspector and other Government inspectors)

  • Energy Authority

  • Gas Authority

  • Water Authority

  • Other (including contractors)

  • Company details
  • Company name and personnel

Source of alarm

  • Check box if alarm activation notified CPM of incident

  • Smoke detector?

  • Thermal detector?

  • Sprinkler?

  • Break Glass Alarm (Manual Call Point)?

  • Security Alarm?

  • Other (including phone calls)?

  • Caller ID
  • Caller name and phone number

Fire Details

  • Check box if there was a fire associated with the incident?

  • Electrical

  • Ordinary combustibles

  • Flammable liquid

  • Other (including vehicle)


  • Check box if injuries were reported

  • UMMS Staff

  • Injured Party Details
  • Name

  • Contact Phone Number

  • Staff Supervisor, Number

  • Detail of injuries

  • Injured Party Details
  • Name

  • Contact Phone Number

  • Student number

  • Detail of Injuries

  • Visitors

  • Injured party details
  • Name

  • Contact phone number

  • Reason for visit to University of Maryland Medical System

  • Detail of Injuries

Witness statement(s) relating to the incident

    Witness statement
  • Name

  • Contact Phone Number

  • Statement

Further images related to incident

  • Other Images

Sign off

  • Signature

  • Time report completed

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.