General Information
Date and time of incident
Date and time incident was reported.

To whom was the incident reported?

Supervisor's Name

Was there any witness(es)? If yes, provide name(s).


Name (Person 1):




Job Title:

Time on job: (Yrs & Mos)

Employee Disposition Status:

Medication prescribed? If yes list medications.

Enter witness #1 statement

Add signature
Enter witness #2 statement

Add signature
Enter witness #3 statement
Add signature
Add signature

Describe injury.

Detail any first-aid or medical treatment administered. (Provide names)

Was there any Property Damage?

Photo of damage.

Any equipment involved?

We're there any vehicles involved?


Was any equipment involved?

Equipment Asset number:

Describe Incident

Detailed description of just prior to and incident. (Include environmental conditions at time of incident)

Environmental photo:

Immediate (Direct Causes):

Direct cause photo:

Contributing (underlying) Factors:

Contributing factors photo:

Corrective Action (Include detail description of action and person(s) responsible for actions)

What was the potential for severity?

What could have potentially happened?

What is the probability of reoccurrance?
Name of Investigator
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.