Incident Report Template

• Incident Type (pick one)

  Vehicle/Equipment Damage

  First Aid (no lost time)

  Medical Treatment (lost time)

  Serious Harm

  Fatality

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

• Conducted on

  Date

• Prepared by

• Location
  Address

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

Incident Details

• Take photo of surrounding environment including any annotations

  Media

• 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

  Sign