This general template can be used for all incidents, however it is important to check with your state regulatory body requirements and/or Insurer as to the legal reporting requirements. You can modify this template to suit your workplace needs.
Enter job description
What was the Incident/ Near Miss?
Were there any injuries?
Description of injury
Was there any damage to property or plant?
Description of damage
What caused the incident?
What actions will be taken to eliminate future repeats of the incident?
Signed off by supervisor when corrective actions have been adopted and monitored