Title Page

  • Job

  • Conducted on

  • Prepared by

  • Location
  • 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

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.