Title Page

  • Conducted on

  • Prepared by

  • Location

Hazard and Incident Details

  • Incident Category

1. Injured Person (if applicable)

  • Take photo of injured person (where appropriate)

  • Name

  • DOB

  • Sex

  • Contact Number/ Email

2. Job Details (if applicable)

  • Job Title

  • How long in this occupation

  • Start time

  • Hours worked

  • Shift arrangement

  • Training/ Qualifications

3. Hazard/ Incident Details

  • Occurred

  • Reported

  • Location of incident
  • Description of hazard incident

  • Description of any of injury, illness or property damage

  • Take/ upload photo evidence of incident, environment, person(s) involved

  • Date reported to regulatory authority (leave blank if not required)

4. Witness Statements (if applicable)

  • Name

  • Contact

  • Statement

  • Witness signature (if applicable)

5. Completion

  • Observations and comments

  • Name and signature of reporting person

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.