• Insert Project and Brief Incident Description

  • Date/Time of Incident

  • Prepared by

  • Document No.

Incident Details

Details of the Incident

  • Description of the Incident:

  • Location:

  • Name/s of persons involved:

  • Staff dealing with incident:

  • Staff attending incident site:

  • Responsible Supervisor/Manager:

Immediate Action Taken

  • Provide details of any corrective action taken at the time of this report:

Incident Type

  • Safety and Health

  • Environment

  • Community

  • Non-SHE

  • Fatality/s

  • Lost Time Injury / Taken to Hospital

  • Medical Treatment Injury

  • First Aid Injury

  • Near Miss

  • Property Damage

  • Security Breach

  • Hazard

  • Procedural Breach

  • Other

  • Other description

Drug and Alcohol Testing

  • Drug and alcohol testing undertaken?

  • Breath test returned?

  • Urine test returned?

  • Awaiting arrival of tester?

Incident Classification

  • Class 1

  • Level 1

  • Class 2

  • Level 2

  • EPC1

  • PC1

Sign off

  • Name

  • Signature

  • Phone number

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.