• Document No.

What is being reported

  • A near miss or dangerous occurrence

  • Damage to a building or property

  • An incident resulting in injury

  • A violent incident

  • A case of work related ill health

  • When did the incident occur

  • Client / Site

  • Wide area picture of site

  • Prepared by

Part A

PART A - To be completed by the person reporting the incident or the injured person

Description of incident

  • What was the exact location of the incident. Include address, building or grid reference and room name/number.
  • What happened? Describe the incident. Give as much information as possible. Include what was happening at the time the incident occurred.

  • Relevant photos or video

  • If this was a violent incident, what waste nature of the incident?

Police involvement

  • Were the police informed?

  • Date anytime police informed

  • How were the Police informed?

  • Crime number

  • Notes

Injury details

  • Describe the exact parts of the body injured

  • Full name of injured person

  • Date of birth

  • Male or Female

  • Home address
  • Contact number

  • Employer address if contractor or agency
  • Next of kin name and tel

Classification of injured person

  • Employee

  • Member of public

  • Agency worker

  • Contractor

Witness information

  • We're there any witnesses to this incident?

  • Witness name

  • Witness contact number and email address

  • Witness postal address
  • Witness statement

  • Any photos taken by witnesses


  • Incident reported to at site

  • We're any other agencies or external bodies informed. If so who and when?

  • Who made this report

Part B

To be completed by the relevant responsible person or manager or event organiser

RIDDOR reporting - if anyone was injured were they....

  • An employee who lost consciousness or needed resuscitation

  • An employee who suffered a major injury

  • An employee who was hospitalised for more than 24 hours

  • An employee who was absent for more than 7 consecutive days

  • A member of the public, visitor etc, who was taken to hospital direct from the site of the incident

  • Has the incident been reported under RIDDOR

  • If reported under RIDDOR, when?

  • If reported under RIDDOR, who made the report?


  • What initial treatment was given

  • What happened to the casualty

  • How were they transported and who by

  • If the person went to a medical facility, which one.


  • Detail any potential causes of the incident that have been identified during the initial investigation

  • Relevant media

Actions taken to prevent recurrence

  • Detail all actions taken

  • Is a further detailed investigation required?



  • Add media

  • Add media

  • Add media

  • Add media

  • Add media

  • Add media

  • Add media

  • Add media


  • Add media

  • Add media

  • Add media

Voice notes

  • Add media

  • 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.