Title Page

  • First Report

  • AWS

  • SMI

  • SER

  • STS

  • Job Name

  • Location
  • Client / General Contractor

  • Conducted on

  • Prepared by

  • Fill out the information below to the best of your knowledge. This will help your supervisors with the initial incident investigation report. If any of the questions below do not apply to the incident being reported, put "N/A" in the given spaces.

General Incident Information

  • Date & Time of Incident

  • Type of Incident

  • Specific Incident Location

  • Describe the incident (who, what, when, where, how?)

Injury Information

  • Injury Type

  • Name of Employee

  • Phone Number

  • Occupation

  • Age

  • Years Employed?

  • EMS Notified?

  • Has the injured employee been taken to a clinic/hospital?

  • Clinic Name & Location

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.