Incident Report - First Response

• Document No.

• Name of person reporting

First Incident Details

• Date & Time of Incident

  Date
• Location of Incident
  Address

• Incident Priority?

  Urgent

  High

  Medium

  Low

  Trivial

• Incident Type?

  Select Hazard Near-Miss Slip & Fall Accident Injury Theft Fire Property Damage Fatality Illness Other Reportable / Notifiable Loss Time

  • Hazard
  • Near-Miss
  • Slip & Fall
  • Accident
  • Injury
  • Theft
  • Fire
  • Property Damage
  • Fatality
  • Illness
  • Other
  • Reportable / Notifiable
  • Loss Time

• How serious could it have been?

  Catastrophic or Fatal

  Major

  Minor or moderate

  None

• Likelihood of occurrence

  Highly unlikely (Rare)

  Unlikely

  Moderate

  Likely

  Highly Likely

• If an incident did occur, how serious could it be?

  Catastrophic or Fatal

  Major

  Minor or moderate

  None

• Name of on-duty supervisor at time of incident?

• Immediate medical attention required?

  Yes

  No

• What kind of medical attention was administered or required?

Describe What Happened

• Describe what happened. Please be detailed but state only facts.

Record Evidence and Information

People involved

• Please document all people involved in this incident, including yourself (the person reporting the incident)

Person

Person

• Full Name

• Contact phone number

• Please describe this person's involvement with the incident, including all relevant information

• Does this person wish to make a preliminary statement?

  Yes

  No

  N/A

Preliminary Statement

• Statement regarding incident

• Person Signature

  Sign

• Has this person sustained an injury?

  Yes

  No

Injury Details

• Provide injury details (include any body parts affected)

Corrective Actions

• Are corrective/further actions required with regard to this incident?

  Yes

  No

• Have all required corrective actions been added as Actions to this inspection?

  Yes

  No

  N/A

• Please add any corrective actions to the appropriate questions above before completing this incident report

Sign Off

• Further action/follow-up/investigation required?

  Yes

  No

• Name of person/people to follow up

• Name & Signature of Reporter