Incident Report

If there are any pictures to include, you may upload them on the next page.

Today's Date * +

Time of Incident *

Location of Incident *

(Be specific, e.g. Room Number, etc.)

Indicate Type of Incident *

An Accident Report MUST be filled out first for any Medical Emergency. An Incident Report should include any supporting details beyond what is included in the Accident Report already.

For a Fusion related incident, please be sure to include as much supporting information as possible.

This should include:

- The specific workstation(s) experiencing the issue

- Whether this is a global issue or isolated to one specific area (i.e. EI, Member Services, AP, etc.)

- UID/Member ID of any users involved

- Any steps taken to address the issue already (i.e. exit Fusion, restart computer, try another workstation)

Notifications should be sent to Vania McBean and the appropriate professional staff for the area(s) impacted.

Description of Incident
(Please be detailed, including extent of damage, missing equipment, etc.) *

UM Police Notified? *

Yes

No

Responding Officer's Name *

Case Number *

Staff Information:

Staff Name: *

Staff Email *

Are there additional persons involved to record? *

Yes

No

Persons Involved:

Person #1

First Name

Last Name

UID #

Street Address

City

State

Zip Code

Phone Number

Email Address

Are there additional persons involved to record? *

Yes

No

Person #2

First Name

Last Name

UID #

Street Address

City

State

Zip Code

Phone Number

Email Address

Are there witnesses to record? *

Yes

No

Witness(es):

Witness #1

First Name

Last Name

UID #

Street Address

City

State

Zip Code

Phone Number

Are there additional witnesses to record? *

Yes

No

Witness #2

First Name

Last Name

UID #

Street Address

City

State

Zip Code

Phone Number

Are there pictures to include in this incident report?