2026 CME Incident Reporting Form

  • Incident Reporting Form

  • Your Information

  • Your Department*
  • Primary Work Location:*
  • Date of Reporting*
     - -
  • Are you reporting abuse, assault, neglect, sexual or financial exploitation perpetrated by a CME employee or client?*

  • Incident Reporting Form

  • Type of Incident

  • Please review the descriptions carefully and select the appropriate category that best aligns with the nature of the incident you've encountered. Providing accurate and detailed information will assist us in addressing the situation promptly and implementing preventive measures to enhance safety and mitigate risks.

    Bodily Injury
    Any physical harm sustained by an individual while performing work-related duties. This includes but is not limited to cuts, burns, fractures, sprains, strains, bruises, and any other injuries that require medical attention or result in discomfort or impairment.

    Property Damage
    Any harm inflicted upon tangible assets owned by the organization or its employees during work-related activities. This encompasses damage to buildings, equipment, vehicles, tools, materials, or any other physical property.

    Harassment or Discrimination
    Any unwelcome or harmful behavior directed towards an individual or group based on protected characteristics such as race, ethnicity, gender, sexual orientation, religion, disability, or age. Harassment and discrimination can take various forms, including verbal abuse, intimidation, bullying, and unfair treatment.

    Workplace Hazard
    Any condition or situation within the workplace that has the potential to cause harm, injury, illness, or property damage. Hazards can include unsafe working conditions, environmental risks, inadequate safety protocols, or any other factors that pose a threat to safety.

    Near Miss
    An incident that almost resulted in harm, injury, or damage but was narrowly avoided. Near misses are events where the potential for an accident or injury was present, but no harm actually occurred.

    Security Breach
    Unauthorized access, disclosure, alteration, or destruction of confidential or sensitive information, computer systems, networks, or physical facilities. Security breaches can result in data loss, privacy violations, financial losses, or reputational damage to the organization.

     

  • Please Note: This incident report form is designed to accommodate the reporting of multiple incidents related to the same event. Please ensure that all incidents reported on this form are interconnected and stem from the same event.  If you need to report unrelated incidents, please submit a separate incident report form for each.

  • Please select the type of incident(s) you are reporting from the following options:*

  • Incident Reporting Form

  • Bodily Injury Incident Details

  • Has HR been informed of this Incident?*
  • Date of incident:*
     - -
  • What was your involvement in the incident:*
  • Were there any witnesses to this incident?*
  • Where did this incident take place:*
  • Severity of Injury:*
  • Describe the nature of the injury:*
  • Part(s) of Body Injured*
  • Was first aid administered?*
  • What was administered?*
  • Did the injury require professional medical attention?*
  • Provide details of medical care received:*
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  • Could actions have been taken to prevent this incident?*
  • Did this incident cause time missed from work?*
  • Was time missed paid?*

  • Incident Reporting Form

  • Property Damage Incident Details

  • Has HR been informed of this Incident?*
  • Date of incident:*
     - -
  • What was your involvement in the incident:*
  • Were there any witnesses to this incident?*
  • Where did this incident take place:*
  • Description of Property Damage:*
  • Estimated Value of Damage:*
  • Was the property insured?*
  • Were emergency services contacted?*
  • Which services:*
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  • Could actions have been taken to prevent this incident?*

  • Incident Reporting Form

  • Harassment or Discrimination Incident Details

  • Has HR been informed of this Incident?*
  • Is this report regarding a member of HR?*
  • Is this report regarding your supervisor?*

  • As your report involves HR, please note they will not be included in the review of your report to maintain objectivity and fairness.

  • As your report involves your supervisor, please note they will not be included in the review of your report to maintain objectivity and fairness.

  • Date of incident:*
     - -
  • What was your involvement in the incident:*
  • Were there any witnesses to this incident?*
  • Where did this incident take place:*
  • Type of Harassment/Discrimination:*
  • Affected Party:*
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  • Incident Reporting Form

  • Workplace Hazard Incident Details

  • Has HR been informed of this Incident?*
  • Date of incident:*
     - -
  • What was your involvement in the incident:*
  • Were there any witnesses to this incident?*
  • Where did this incident take place:*
  • Describe the hazard:*
  • Was the hazard previously reported?*
  • When?*
  • Were signage or other warning measures in place?*
  • Why Not?*
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  • Could actions have been taken to prevent this incident?*

  • Incident Reporting Form

  • Near Miss Details

  • Has HR been informed of this near miss?*
  • Date of near miss:*
     - -
  • What was your involvement in the near miss:*
  • Were there any witnesses to this near miss:*
  • Where did this near miss take place:*
  • Potential Severity if Incident Had Occurred:*
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  • Incident Reporting Form

  • Security Breach Incident Details

  • Has HR been informed of this Incident?*
  • Has IT/Facilities been informed of this Incident?*
  • When?*
  • Date of incident:*
     - -
  • What was your involvement in the incident:*
  • Were there any witnesses to this incident?*
  • Where did this incident take place:*
  • Nature of Breach:*
  • Affected Systems/Information:*
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  • Could actions have been taken to prevent this incident?*

  • Incident Reporting Form

  • Reporting Assurance

  • All reports submitted through this form are treated with confidentiality. We are dedicated to safeguarding your privacy and ensuring that your concerns are addressed securely and without fear of retaliation.

  • Are you concerned about retaliation for reporting this incident?*
  • Would you like to have your report reviewed by an independent third-party organization to ensure the process is unbiased and neutral?*

  • Incident Reporting Form

  • Reputation Impact Assessment

  • Certain incidents can significantly impact an organization's reputation, including through social media, media coverage, or public perception. Your input regarding the potential impact of this incident on Community-Minded Enterprises' reputation helps us maintain trust and integrity within our community.

  • Does the incident being reported have the potential to affect Community-Minded Enterprises Reputation?*

  • Incident Reporting Form

  • Employee Attestation

  • I, *, hereby affirm that all the details provided in this incident report are true and accurate to the best of my knowledge and ability. I certify that I have provided all relevant information to the best of my ability.

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