Title Page

  • Document No.

  • Audit Title

  • Client / Site / Project

  • Report conducted on

  • Prepared by

  • Location

First Incident Details

  • Date & Time of Incident

  • Location of Incident
  • Incident Priority?

  • Incident Type?

  • Please describe type of incident

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

  • Is immediate medical attention required?

  • What kind of medical attention was administered?

Describe What Happened

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

  • What were the weather / environmental conditions at the time of the incident?

  • Describe the weather / environmental conditions at the time of the incident

People involved

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

  • Person

Person

  • Full Name

  • Address

  • Contact phone number

  • What is this person's relation to the incident? (select all that apply)

  • Describe this person's relation to the incident

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

  • Has this person sustained an injury?

Injury Details

  • Type of injury or illness? (select all that apply)

  • Describe this injury or illness

  • Parts of body affected? (select all that apply)

  • Please describe injury location

  • What was the cause of this injury or illness?

  • Loss of consciousness?

  • Abnormal Breathing?

  • Major Haemorrhage?

Previous Medical History

  • List any medical history/conditions

Patient Vitals

  • Pulse

  • Blood Pressure

  • SPO2

Treatment

  • Describe treatment details

Corrective Actions

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

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

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

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.