Title Page

  • Incident Title (Dept/EE Name/Incident Type/Date)

  • Document Number

  • Department/Division

  • Site conducted

  • Date and Time of Occurrence

  • Prepared by

  • Location
  • Incident type

Event Details

  • Task or Activity at time of Incident

  • Physical or immediate causes of incident

  • Immediate Actions Taken

  • Description of Incident

Where

  • Specific location of Occurrence

Who

  • Person(s) Involved

  • Relationship of Person Involved

  • Supervisor of Person Involved

  • Date and Time Shift Began

Witnesses

  • Witness

  • Relationship of Witness

Internal Reporting

  • Reported by

  • Date Reported

External Reporting Environmental Release

  • Reportable Environmental Release

  • Environmental Release
  • Chemical Name

  • Release Source

  • Released To

  • Quantity Released

  • Onsite Area Affected

  • Chemical Class

  • Quantity Recovered

  • Offsite area Affected

Weather Conditions

  • Weather Conditions

  • Wind Speed

  • Wind Direction

Remediation

  • Remediation Required

  • DESCRIBE REMEDIATION

Insurance Reporting

  • Insurance Group Notified

  • CLAIMS HANDLER CONTACT INFORMATION

  • INSURANCE CLAIM NUMBER

  • Date Reported

Risk Assessment

  • Open Risk Matrix

  • Consequence

  • Likelihood

  • Risk Level

Root Cause Analysis

  • Root Cause

  • Equipment and Tools

  • Facilities

  • Leadership and Supervision

  • Nature of Task

  • Personal Factors

  • Process Controls

  • Work Processes

  • Working Conditions

  • Cost
  • Cost Type

  • Amount

  • Description

Follow Up Responsibilities

  • Responsible For Incident Investigation

Follow up Responsibilities

  • Responsible for Incident Closure

  • Description of Incident

Where

  • Specific location of Occurrence

Who

  • Person Involved

  • Relationship of Person Involved

  • Supervisor of Person Involved

  • Date and Time Shift Began

Witnesses

  • Witness

  • Relationship of Witness

Event Details

  • Task or Activity at time of Incident

  • Object or Substance that directly injured or made person ill

  • Physical or immediate causes of incident

  • Immediate Actions Taken

External Reporting injury/illness

  • Reportable Injury/Illness?

  • Agency
  • Agency

  • Agency Contact Info

  • External Report Number

  • Reported Date

Insurance Reporting

  • Insurance Group Notified

  • CLAIMS HANDLER CONTACT INFORMATION

  • INSURANCE CLAIM NUMBER

  • Date Reported

Treatment Provided

  • First Aid or Medical Aid?

  • First Aid Responder

  • Description of Treatment Provided

Safe Work Practices

  • ALCOHOL TEST PERFORMED?

  • Date and Time of Test

  • DRUG TEST PERFORMED?

  • Date and Time of Test

Classification

  • Injury Classification

  • Estimated Restricted Days

  • Description of restrictions

  • First Restricted Day

  • Date Returned

  • Number of restricted days

  • Estimated Lost Days

  • First Lost Day

  • Date Returned

  • Number of Lost work days

  • Date of fatality

Injury/Illness Details

  • Type of Injury/Illness

  • Body Part

  • Left or right

  • Accident Type

  • Accident Agent

Safe Work Practices

  • Was PPE Worn?

  • PPE Worn

  • Describe PPE Worn

Risk Assessment

  • Open Risk Matrix

  • Consequence

  • Likelihood

  • Risk Level

Root Cause Analysis

  • Root Cause

  • Equipment and Tools

  • Facilities

  • Leadership and Supervision

  • Nature of Task

  • Personal Factors

  • Process Controls

  • Work Processes

  • Working Conditions

  • Cost
  • Cost Type

  • Amount

  • Description

Follow up Responsibilities

  • RESPONSIBLE FOR INCIDENT INVESTIGATION REVIEW

Follow up Responsibilities

  • Responsible for Incident Closure

  • Description of Incident

Where

  • Specific location of Occurrence

Who

  • Person Involved

  • Relationship of Person Involved

  • Supervisor of Person Involved

  • Date and Time Shift Began

Witnesses

  • Witness

  • Relationship of Witness

Event Details

  • Task or Activity at time of Incident

  • Physical or immediate causes of incident

  • Immediate Actions Taken

External Reporting Motor Vehicle Incident

  • Reportable Motor Vehicle Incident?

  • Agency
  • Agency

  • Agency Contact Info

  • External Report Number

  • Reported Date

Safe Work Practices

  • ALCOHOL TEST PERFORMED?

  • Date and Time of Test

  • DRUG TEST PERFORMED?

  • Date and Time of Test

Weather Conditions

  • Weather Conditions

  • Wind Speed

  • Wind Direction

Motor Vehicle Incident Information

  • Physical Cause

  • Posted Speed Limit

  • Road Conditions

  • Road Type

  • Visability

  • Police Report Filed

  • Vehicle Information
  • Driving Activity

  • Driving Speed

  • Vehicle Ownership

  • Vehicle ID Number

  • Vehicle Plate #

  • Drivers Liscense Number

  • Duty Status

  • Condition of Driver

  • Driver wearing their seatbelt?

  • Citation Issued?

  • Driver Information

  • Number of Passengers Injured:

  • Number of Passengers:

  • Contact #:

Risk Assessment

  • Open Risk Matrix

  • Consequence

  • Likelihood

  • Risk Level

Root Cause Analysis

  • Root Cause

  • Equipment and Tools

  • Facilities

  • Leadership and Supervision

  • Nature of Task

  • Personal Factors

  • Process Controls

  • Work Processes

  • Working Conditions

Insurance Reporting

  • Insurance Group Notified

  • CLAIMS HANDLER CONTACT INFORMATION

  • INSURANCE CLAIM NUMBER

  • Date Reported

  • Cost
  • Cost Type

  • Amount

  • Description

Follow up Responsibilities

  • RESPONSIBLE FOR INCIDENT INVESTIGATION REVIEW

Follow up Responsibilities

  • Responsible for Incident Closure

  • Description of Incident

Where

  • Specific location of Occurrence

Who

  • Person Involved

  • Relationship of Person Involved

  • Supervisor of Person Involved

  • Date and Time Shift Began

Witnesses

  • Witness

  • Relationship of Witness

Event Details

  • Task or Activity at time of Incident

  • Physical or immediate causes of incident

  • Immediate Actions Taken

External Reporting Fire/Explosion

  • External Reporting Fire/Explosion ?

  • Agency
  • Agency

  • Agency Contact Info

  • External Report Number

  • Reported Date

Insurance Reporting

  • Insurance Group Notified

  • CLAIMS HANDLER CONTACT INFORMATION

  • INSURANCE CLAIM NUMBER

  • Date Reported

Fire Information

  • Ignition Source

  • Extinguishing Method

  • Time to Extinguish Fire

Risk Assessment

  • Open Risk Matrix

  • Consequence

  • Likelihood

  • Risk Level

Root Cause Analysis

  • Root Cause

  • Equipment and Tools

  • Facilities

  • Leadership and Supervision

  • Nature of Task

  • Personal Factors

  • Process Controls

  • Work Processes

  • Working Conditions

  • Cost
  • Cost Type

  • Amount

  • Description

Follow up Responsibilities

  • RESPONSIBLE FOR INCIDENT INVESTIGATION REVIEW

Follow up Responsibilities

  • Responsible for Incident Closure

  • Description of Incident

Where

  • Specific location of Occurrence

Who

  • Person Involved

  • Relationship of Person Involved

  • Supervisor of Person Involved

  • Date and Time Shift Began

Witnesses

  • Witness

  • Relationship of Witness

Event Details

  • Task or Activity at time of Incident

  • Physical or immediate causes of incident

  • Immediate Actions Taken

Insurance Reporting

  • Insurance Group Notified

  • CLAIMS HANDLER CONTACT INFORMATION

  • INSURANCE CLAIM NUMBER

  • Date Reported

Risk Assessment

  • Open Risk Matrix

  • Consequence

  • Likelihood

  • Risk Level

Root Cause Analysis

  • Root Cause

  • Equipment and Tools

  • Facilities

  • Leadership and Supervision

  • Nature of Task

  • Personal Factors

  • Process Controls

  • Work Processes

  • Working Conditions

  • Cost
  • Cost Type

  • Amount

  • Description

Follow up Responsibilities

  • RESPONSIBLE FOR INCIDENT INVESTIGATION REVIEW

Follow up Responsibilities

  • Responsible for Incident Closure

  • Description of Incident

Where

  • Specific location of Occurrence

Who

  • Person Involved

  • Relationship of Person Involved

  • Supervisor of Person Involved

  • Date and Time Shift Began

Witnesses

  • Witness

  • Relationship of Witness

Event Details

  • Task or Activity at time of Incident

  • Object or Substance that directly injured or made person ill

  • Physical or immediate causes of incident

  • Immediate Actions Taken

External Reporting injury/illness

  • Reportable Injury/Illness?

  • Agency
  • Agency

  • Agency Contact Info

  • External Report Number

  • Reported Date

Insurance Reporting

  • Insurance Group Notified

  • CLAIMS HANDLER CONTACT INFORMATION

  • INSURANCE CLAIM NUMBER

  • Date Reported

Treatment Provided

  • First Aid or Medical Aid?

  • First Aid Responder

  • Description of Treatment Provided

Classification

  • Injury Classification

  • Estimated Restricted Days

  • Description of restrictions

  • First Restricted Day

  • Date Returned

  • Number of restricted days

  • Estimated Lost Days

  • First Lost Day

  • Date Returned

  • Number of Lost work days

  • Date of fatality

Injury/Illness Details

  • Type of Injury/Illness

  • Body Part

  • Left or right

  • Accident Type

  • Accident Agent

Safe Work Practices

  • Was PPE Worn?

  • PPE Worn

  • Describe PPE Worn

Safe Work Practices

  • ALCOHOL TEST PERFORMED?

  • Date and Time of Test

  • DRUG TEST PERFORMED?

  • Date and Time of Test

Risk Assessment

  • Open Risk Matrix

  • Consequence

  • Likelihood

  • Risk Level

Root Cause Analysis

  • Root Cause

  • Equipment and Tools

  • Facilities

  • Leadership and Supervision

  • Nature of Task

  • Personal Factors

  • Process Controls

  • Work Processes

  • Working Conditions

  • Cost
  • Cost Type

  • Amount

  • Description

Follow up Responsibilities

  • RESPONSIBLE FOR INCIDENT INVESTIGATION REVIEW

Follow up Responsibilities

  • Responsible for Incident Closure

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.