Information

  • Centre / Site

  • Conducted on

  • Incident report prepared by

  • Job title and department

  • Do be courteous always Do obtain photos of incidents and surrounding area
    Do obtain witness statements and contact details Do Not accept liability Do Not make a judgement on who is at fault.

Incident Report

Personal Details

  • Incident Type

  • Name of injured / affected person(s)

  • Gender

  • Address of injured / affected person(s)

  • Contact Number

  • Date of birth of injured / affected person(s)

  • Were any utilities affected?

Detail description of the event:

  • undefined

Incidents slip, trip or fall related

  • Date and time incident was reported.

  • Location of incident. (Specify site location)

  • To whom was the incident reported?

  • Weather conditions? (for incidents in open areas)

  • Lighting / visibility conditions?

  • Wet floor sign present?

  • Floor Condition?

  • Was the injured person wearing appropriate footwear?

  • Was the injured person carrying anything at the time of the incident?

  • Damaged clothing or footwear?

  • Was the incident captured by CCTV?

  • CCTV Reference or file name?

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

  • Name and contact of witness 1

  • Statement of witness 1

  • Signature of witness 1

  • Name and contact of witness 2

  • Statement of witness 2

  • Signature of witness 2

  • Name and contact of witness 3

  • Statement of witness 3

  • Signature of witness 3

Details of injury, if applicable

  • Describe injury.

  • How did the injury/damage occur and what caused it?

  • What was the injured/affected person(s) actually doing at the time of the accident/incident?

  • Describe body parts affected.

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

  • Details of first-aid supplies used.

  • Details of relevant existing conditions.

  • Details of relevant medications.

  • First Aider(s) name and call signs

  • If no treatment provided, why?

Police

  • Police called / informed?

  • Time of the call to Police?

  • Time Police attended?

  • Police unit attended shoulder number?

  • Police crime / incident reference number?

Ambulance / Paramedics

  • Ambulance / Paramedics called?

  • Time of the call to Ambulance / Paramedics?

  • Time Ambulance / Paramedics attended?

  • Ambulance / Paramedics unit shoulder number?

Fire Brigade

  • Fire Brigade called?

  • Time of the call to Fire Brigade?

  • Time Fire Brigade attended?

  • Fire Brigade unit shoulder number?

Events involving property damage

  • Property / building fabric damage:

  • Photo of damage.

  • Was center machinery / equipment involved (compactors / lifts / escalators / MEWP)?

  • Was contractor / delivery or third party machinery, vehicle or equipment involved?

  • Vehicle ID:

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

  • Environmental photo:

  • Immediate (Direct Causes):

  • Direct cause photo:

Events involving Fire or Gas

  • What type of incident occurred?

  • Did the alarm / alert system activated?

  • What caused the activation?

  • Did center evacuate?

  • If there was an evacuation, what time were people allowed to return?

Analysis

  • Contributing (underlying) Factors:

  • Contributing factors photo:

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

  • What could have potentially happened?

  • What is the probability of reoccurrance?

Additional notes if required

  • Notes

  • Date & Time

  • Name and signature

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.