Title Page

  • Incident Type (pick one)

  • Injured body part (be specific or mark N/A)

  • Conducted on

  • Prepared by

  • Location
  • What happened? Were there any contributing factors? Was anyone else involved?

Incident Details

  • Take photo of surrounding environment including any annotations

  • What actions will be taken to eliminate future repeats of the incident?

  • Other comments

Sign Off

  • People leaders sign off that all actions have been completed

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.