Incident Report Template

• Name:

• Conducted on

  Date

• Prepared by

• Location
  Address

• 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

• Name

• Phone Number

• Date and time of incident

  Date

• What was the Incident/ Near Miss?

• Were there any injuries?

  Yes

  No

• Description of injury

• Take photo of injury or incident (If necessary)

  Media

• What caused the incident?

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

• Management comments

Sign Off

• Signed off by Trustee / Administrator when corrective actions have been adopted and monitored

• Trustee sign off

  Sign