Title Page

  • Company Name

  • Job Name

  • Job Location
  • Conducted on

  • Incident Type

  • Prepared by

Near Miss

  • 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, leave the space blank or type "N/A".

General Incident Information

  • Date & Time of Incident

  • Time Work Started

  • Specific Incident Location

  • Witnesses?

Near Miss

  • List person(s) involved

Incident Description

  • Describe clearly what took place. Include materials, equipment, and environmental conditions involved in the incident. Provide information that led up to the incident. Include photos by selecting "Add Media" below. (Who - what - when - where - why - how?)

  • Enter description here

  • Add media

  • Lessons learned?

Injury

  • 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, leave the space blank or type "N/A".

General Incident Information

  • Date & Time of Incident

  • Time Work Started

  • Specific Incident Location

  • Witnesses?

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

Incident Description

  • Describe clearly what took place. Include materials, equipment, and environmental conditions involved in the incident. Provide information that led up to the incident. Include photos by selecting "Add Media" below. (Who - what - when - where - why - how?)

  • Enter description here

  • Add media

Property Damage

  • 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, leave the space blank or type "N/A".

General Incident Information

  • Date & Time of Incident

  • Time Work Started

  • Specific Incident Location

  • Witnesses?

Property Damage

  • Nature of Damage

  • Equipment/Machinery Involved

  • Make/Model/Equipment Number

  • List person(s) involved

Incident Description

  • Describe clearly what took place. Include materials, equipment, and environmental conditions involved in the incident. Provide information that led up to the incident. Include photos by selecting "Add Media" below. (Who - what - when - where - why - how?)

  • Enter description here

  • Add media

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.