Title Page

  • Conducted on

  • Prepared by

  • Location

Incident / Accident Report

Person Impacted

  • Date and time of incident

  • Who was the person affected, injured or impacted?

  • Persons Full Name

  • Persons Date of Birth

  • Persons Email Address

  • Persons Mobile or Other Phone

Location of Incident

  • Where did the incident occur?

  • Address where the incident occurred?

  • Please add any additional information on the location of the incident?

Incident Details

  • Type of Incident

  • Details of Incident

  • Please upload any files, photos or videos to assist with information capture

Actions Taken

  • What actions were taken as a result of the incident?

  • Please describe the specific details of the actions taken as a result of the incident

  • Are additional actions required to eliminate future repeats of the incident?

  • Is follow up required with the impacted person?

Other Parties / Witness

  • List any witnesses or other parties here. Please include their full name, relationship (if any to the impacted person) and all contact details including phone and email information.

Sign Off

  • Reporting persons name

  • Position held

  • Contact phone number

  • Signature

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.