Anonymous

Incident Report

Download and use this free general incident report template to capture photo evidence of the incident and injury, capture signatures of the parties involved. You may wish to modify this template so it is more appropriate for your site or workplace needs.

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Use this Template

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Title Page

Job
Conducted on
Prepared by
Location

Incident Investigation

Incident Details

What was the Incident/Near Miss?
Date and time of incident
York Vehicle registration
Vehicle Type
- Truck
- Trailer
- Crane Truck
- Bakkie
- Bell Tri Logger
- Tractor
- Fire Truck
- Car
- Forwarder
- Harvesting Machine
Vehicle License Disc
York Driver Name
York Driver License
York Driver ID

York Driver Statment

Driver Statement
Driver Signature
Were there any injuries?
Description of injury
Take photo of injury
Was there any damage to property or plant?
Description of damage
Take photo of damage
What caused the incident?
Take photo of surrounding environment including any annotations
What actions will be taken to eliminate future repeats of the incident?
Management comments
Is recovery required

Sign Off

Signed off by supervisor when corrective actions have been adopted and monitored
Supervisor sign off

Anonymous

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.