General Incident Report Template

• Conducted on

  Date

• Prepared by

• Location
  Address

• This general template can be used for all incidents. You can modify this template to suit your workplace.

Incident Details

• Enter job number

• Enter job description

• Date and time of incident

  Date

• What was the incident/ near miss?

• Were there any injuries?

  Yes

  No

• Was there any damage to property or plant?

  Yes

  No

• What caused the incident?

• Take photos of surrounding environment including any annotations

  Media

• What actions will be taken to eliminate future repeats of the incident?

• Supervisor comments

Sign Off

• Signed off by supervisor when corrective actions have been adopted and monitored

• Supervisor sign off

  Sign