Title Page

  • Prepared by

  • Documented on

  • Worksite

  • Location

Incident Details

1. General Information

  • Type of Incident

  • Date and time of when the incident occurred

  • Location of incident (be specific as possible)

  • What was the work being done?

  • Describe the incident

  • Attach or take photo of surrounding environment including any annotations

2. Damages and Injury

  • Incident Category

  • Please specify

  • Attach or take photo evidence of damages and injury (where appropriate)

  • Describe in detail

  • Attach or take photo evidence of damages or injury (where appropriate)

3. Affected Individual(s)

  • Were there people involved in the incident?

  • Click + to add affected individual(s)

  • Person
  • Name

  • Sex

  • Job Title

  • How long in this occupation

  • Start time

  • Hours worked

  • Shift arrangement

  • Training/ Qualifications

  • Contact Number

4. Witness Statements (if applicable)

  • Were there witnesses?

  • Witness
  • Name

  • Contact

  • Statement

  • Witness signature (if applicable)

5. Corrective Actions

  • What actions will be taken to eliminate future repeats of the incident? (Assign action to respective member in the organization)

Completion

  • Management comments

  • Name and signature of reporting person

  • Supervisor sign-off

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.