Kara Ross

Incident Report

This form is to report any incidents including near misses. It is very important to us, especially that near misses are reported, because a near incident without any damage or injury is a great opportunity for us to review policies and procedures and implement actions to prevent it from being an larger issue in the future! If you screw up and are lucky to have everything okay, we want to know to protect the next person from the same type of situation. It's a great thing!

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Title Page

Job location
Conducted on
Form prepared by
Location of incident (indoors/outdoors/toilet/etc.)

Incident information

NOTE:

Incident Details

Enter job description
Date and time of incident
What was the Incident/ Near Miss?
Were there any injuries?
Was first aid reqiured
What first aid was completed
Was hospital transport required?
Was 911 called and ambulance transported?
Description of injury
Take photo of injury if applicable
Was there any damage to property?
Description of damage
Take photo of damage
What caused the incident?
Take photo of surrounding environment and include any descriptions
What actions should be taken to eliminate future repeats of the incident?
Management comments

Sign Off

Witness to incident?
Name and phone number of witness
Signed off by supervisor when corrective actions have been adopted and monitored
Supervisor sign off

Kara Ross

Incident Report

Use this Template

Print as PDF

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.