When did the incident happen?
Incident Information

Has someone been hurt?

Injured Person- Basic Information

Name ( First and Last)

Contact phone number for injured person


Please specify

How many hours has the injured person been on shift?
Where are they hurt?

Please specify

What type of injury?

Please specify

Does the injured person require medical treatment?

Has anything been damaged?

What has been damaged?

Have Police or Fire services been called?

Incident Details

Where did the incident happen?

Equipment or materials involved:

Describe the incident

Please add a photo when applicable

Have any actions been taken to prevent this from happening again?

Describe actions taken to prevent this from happening again.

Signature and Review

I have reported this incident to the best of my knowledge and any actions that can be taken have been done or are planned to prevent recurrence.

Name of person completing this incident report:


Investigation, Preventive Measures and Analysis

Investigative notes:

Please add photos when applicable
What action has Been taken or is planned to prevent recurrence

How will the above action(s) improve operations?

Who is responsible for ensuring the above is done?

When and how will we monitor the effectiveness of the above preventative measures?

Signature and Review

I have reviewed this report, I am confident that the incident was thoroughly analyzed and proper actions have been taken or are planned to be taken to prevent recurrence.

Analysis By Health and Safety Advisor

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.