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NOTE:
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.

Incident Details

Enter job description

Date and time of incident

What was the Incident/ Near Miss?

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

Sign Off

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

Supervisor sign off

Incident Report Template Checklist

Created by: SafetyCulture Staff | Industry: General | Downloads: 240

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.

Signup for a free iAuditor account to download and edit this checklist. It will be added to your free account and you will be able to conduct inspections from your mobile device.

Download and edit this free checklist

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Audit

NOTE:
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.

Incident Details

Enter job description

Date and time of incident

What was the Incident/ Near Miss?

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

Sign Off

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

Supervisor sign off