UMMS Incident Report

• Report Title

• Report Conducted on

  Date

• Report Prepared by

  Sign
• Location
  Address

• Weather Conditions

  Good

  Fair

  Poor

  N/A

• Time incident occurred

  Date

Type of Incident

• undefined

  Select Personal Injury Building Fire (incl alarm) Grass / Garden Fire Car Fire Motor Vehicle Accident Property Loss (individual) Property Loss (UC property) Crime against Person Gas leak or other HAZMAT Flood (water ingress) Other

  • Personal Injury
  • Building Fire (incl alarm)
  • Grass / Garden Fire
  • Car Fire
  • Motor Vehicle Accident
  • Property Loss (individual)
  • Property Loss (UC property)
  • Crime against Person
  • Gas leak or other HAZMAT
  • Flood (water ingress)
  • Other

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
  Address

• Check box if incident occurred within a building

• Building Name

• Floor

• Room number

• Images of incident location ( only as needed )

  Media

Personnel Responding

• UMMS CPM

  Yes

  No
Person

• Name

Person

• Name

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

• Fire

  Yes

  No

• Police

  Yes

  No

• Ambulance Service

  Yes

  No

• State Emergency Service

  Yes

  No

• Other Respondants (including contractors)?

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

  Yes

  No

• Energy Authority

  Yes

  No

• Gas Authority

  Yes

  No

• Water Authority

  Yes

  No

• Other (including contractors)

  Yes

  No
Company details

• Company name and personnel

Source of alarm

• Check box if alarm activation notified CPM of incident

• Smoke detector?

  Yes

  No

• Thermal detector?

  Yes

  No

• Sprinkler?

  Yes

  No

• Break Glass Alarm (Manual Call Point)?

  Yes

  No

• Security Alarm?

  Yes

  No

• Other (including phone calls)?

  Yes

  No
Caller ID

• Caller name and phone number

Fire Details

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

• Electrical

  Yes

  No

  N/A

• Ordinary combustibles

  Yes

  No

  N/A

• Flammable liquid

  Yes

  No

  N/A

• Other (including vehicle)

  Yes

  No

  N/A

Injuries

• Check box if injuries were reported

• UMMS Staff

  Yes

  No

  N/A
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

  Yes

  No

  N/A
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

  Media

Sign off

• Signature

  Sign

• Time report completed

  Date