Title Page

  • Document No.

  • Name of person reporting

First Incident Details

  • Date & Time of Incident

  • Location of Incident
  • Incident Priority?

  • Incident Type?

  • How serious could it have been?

  • Likelihood of occurrence

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

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

  • Immediate medical attention required?

  • 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


  • 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?

Preliminary Statement

  • Statement regarding incident

  • Person Signature

  • Has this person sustained an injury?

Injury Details

  • Provide injury details (include any body parts affected)

Corrective Actions

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

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

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

Sign Off

  • Further action/follow-up/investigation required?

  • Name of person/people to follow up

  • Name & Signature of Reporter

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.