The WRHA has an Injury/Near Miss (INM) form. This is a five page form that is available from your Supervisor/Team Manager or office planning area.

MNU Worksite 97 is encouraging all members to fill out the INM form for any instance of nurse abuse and other near miss occurrences. Nurses are advised to continue to fill out WRHA Occurrence Report Forms in addition to the INM forms. Once complete these forms should be forwarded to your Team Managers.

This comprehensive form contains three sections...

Section I: Injury/Near Miss Details - is to be completed by the employee. Incident categories include...

1. Injury/Illness
2. Motor Vehicle Accident
3. Near Miss
4. Significant Property Damage
5. Other

Section II: Direct Causes - is to be completed by the employee and the designated "in charge" person. Injury/Near Miss categories include...

1. Exertion
2. Falls
3. Struck/Bumped/Banged/Hit by/Rubbed/Abraded
4. Caught In/Under/Between Wall, Equipment, Door
5. Exposure to Hazardous Substance/Agent
6. Violence and Aggressive Behavior
7. Drug/Immunization Reaction
8. Other Allergic Reactions
9. Critical Incident
10. Natural Disaster/Forces of Nature

Section III: Indirect Causes - is to be completed by the employee and the designated "in charge" person

1. Equipment/Device/Material
2. Environment
3. Patient/Resident/Client Related Factors
4. Organizational/Administrative
5. Task

Employer Follow Up

• Once the form is completed by the nurse the designated "in charge person" needs to initiate a Preventive/Corrective Measure Plan of Action.
• The form is then forwarded to the Occupational Environmental Safety and Health Department.
• With in 24 hours the form will be faxed to the Workplace Health and Wellness Unit, the Payroll Department, the Team Manager and the Workers Compensation Board if applicable.
• Serious injuries must be reported to the Provincial Office of Manitoba Labour Workplace Safety and Health Division.