• Name

  • Date and time of incident

  • Date and time incident was reported.

  • Approximate Length of employment, in months

  • Name and address of hospital, if applicable.
  • Photo of doctor's release note.

  • To whom was the incident reported?

  • Location of incident. (Specify site location)

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

  • Activity/ task engaged in at time of incident/ accident

  • Employee's normally assigned task

  • Related training received by employee

  • Date of training


  • Describe injury.

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

  • Immediate action taken


  • Property Damage:

  • Photo of damage.

  • Property Damage:

  • Photo of damage.

  • Vehicle ID:

  • Detailed description of incident. (Include environmental conditions at time of incident)

  • Environmental photo:

  • Immediate (Direct Causes):

  • Direct cause photo:

  • 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?

  • Any previous, similar, or related incidents/ accidents

  • Date of previous incident

  • Actions taken to prevent this or similar incidents/ accidents

  • Any additional recommendations

  • Signature

  • Select date

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. Any ratings or scores displayed in our Public Library have not been verified by SafetyCulture for accuracy. Users of our platform may provide a rating or score that is incorrect or misleading. You should independently determine whether the template is suitable for your circumstances. You can use our Public Library to search based on criteria such as industry and subject matter. Search results are based on their relevance to your search and other criteria. We may feature checklists based on subject matters we think may be of interest to our customers.