Title Page
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Conducted on
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Prepared by
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Location
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This general template can be used for all incidents. You can modify this template to suit your workplace.
Incident Details
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Enter job number
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Enter job description
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Date and time of incident
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What was the incident/ near miss?
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Were there any injuries?
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Was there any damage to property or plant?
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What caused the incident?
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Take photos of surrounding environment including any annotations
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What actions will be taken to eliminate future repeats of the incident?
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Supervisor comments
Sign Off
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Signed off by supervisor when corrective actions have been adopted and monitored
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Supervisor sign off
