Information

  • Site Name

  • PM / SM Name:

  • Conducted on:

  • 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

  • Role

  • 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:

  • H&S DEPARTMENT USE ONLY

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

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.