Title Page

  • Title (Incident - Your Name - Date of Incident)

  • Site

  • Date reported

  • Who is reporting?

  • Reported by

  • Email of person reporting

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

Record Evidence and Information

  • Which of the following do you need to attach to this report to accuractly document this incident?

Evidence Log

  • Please log all relevant evidence below

  • Evidence
  • Evidence Description

  • Evidence ID number (if applicable)

  • Type of evidence

  • Photos of evidence (if applicable)

  • Please detail any further information regarding this evidence (if applicable)

Vehicle Log

  • Please log all relevant vehicle details below

  • Vehicle
  • Vehicle Make

  • Vehicle Model

  • Vehicle Registration

  • Driver (if applicable)

  • Photos of equipment (if applicable)

  • Please detail any further information regarding this vehicle (if applicable)

Damage Log

  • Please log all relevant damage details below

  • Damage
  • Damage description

  • ID number (if applicable)

  • Photos of damage (if applicable)

  • Please detail any further information regarding this damage (if applicable)

Other Items Log

  • Please log all relevant details of other items below

  • Item
  • Item description

  • ID number (if applicable)

  • Photos of item (if applicable)

  • Please detail any further information regarding this item (if applicable)

Equipment Log

  • Please log all relevant equipment details below

  • Equipment
  • Equipment Make

  • Equipment Model

  • Equipment ID number (if applicable)

  • Photos of equipment (if applicable)

  • Please detail any further information regarding this equipment (if applicable)

People involved

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

  • Person

Person

  • Full Name

  • ID number

  • 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

  • Does this person wish to make a preliminary statement?

Preliminary Statement

  • Statement regarding incident

  • Person Signature

  • Has this person sustained an injury?

Injury Details

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

  • Describe type of injury or illness

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

  • Please describe injury location

  • Describe this injury or illness

  • What was the cause of this injury or illness?

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.