Incident Report Form

• Prepared by

• Documented on

  Date

• Worksite

  Compound 1-A

  Coumpound 1-B

  Coumpound 1-C
• Location
  Address

1. General Information

• Type of Incident

  Non-fatal

  Fatal

• Date and time of when the incident occurred

  Date

• 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

  Media

2. Damages and Injury

• Incident Category

  Select Injury/ Illness Property Damage Environmental Incident Vehicle Incident Fire Incident Other

  • Injury/ Illness
  • Property Damage
  • Environmental Incident
  • Vehicle Incident
  • Fire Incident
  • Other

• Please specify

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

  Media

• Describe in detail

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

  Media

3. Affected Individual(s)

• Were there people involved in the incident?

  Yes

  No

• Click + to add affected individual(s)

Person

• Name

• Sex

  Male

  Female

• Job Title

• How long in this occupation

• Start time

  Date

• Hours worked

  8 hours or less

  More than 8 hours

• Shift arrangement

  Fixed shift

  Rotating shift

• Training/ Qualifications

  Select Induction Task specific Trade None of the above

  • Induction
  • Task specific
  • Trade
  • None of the above

• Contact Number

4. Witness Statements (if applicable)

• Were there witnesses?

  Yes

  No
Witness

• Name

• Contact

• Statement

• Witness signature (if applicable)

  Sign

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

  Sign

• Supervisor sign-off

  Sign