• Location

  • Investigation Ref No #:

  • Date of occurrence

  • Date reported

Type of Incident. Select all that apply.

  • Near Miss

  • First Aid

  • Medical Aid

  • Restricted Work

  • Lost Time Injury

  • Occupational Illness

  • Fire or Explosion

  • Equipment Failure

  • Property Damage

  • Material or Business Loss

  • Motor Vehicle Accident

  • Threats

  • Other


  • What type of injury?

  • What body part was injured?

  • Was follow-up treatment required?

  • If incident was reported to RIDDOR, state reference:

Person Involved

  • Persons name

  • Date of Birth

  • Address

  • Department

  • Contact details


  • Clearly describe how the incident occurred.

  • Add media


  • Include the names and phone numbers of any witnesses to the incident. Attach witness statements or cross refer to statements.


  • Immediate causes; what acts and/or conditions contributed directly to this accident?

  • Basic causes; what are the contributing factors? (Job factors, personal factors)


  • What action or recommendations are required to be made to prevent recurrence?

  • When are actions or recommendations required to be implemented by?

Frequency Potential

  • Frequent

  • Probable

  • Occasional

  • Remote

  • Improbable


  • Catastophic

  • Critical

  • Moderate

  • Minor

Costs (if applicable).

  • Estimated:

  • Actual:


  • Action required:

  • Investigated by:

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. Any ratings or scores displayed in our Public Library have not been verified by SafetyCulture for accuracy. Users of our platform may provide a rating or score that is incorrect or misleading. You should independently determine whether the template is suitable for your circumstances. You can use our Public Library to search based on criteria such as industry and subject matter. Search results are based on their relevance to your search and other criteria. We may feature checklists based on subject matters we think may be of interest to our customers.