Internal Incident Report - Template

• Incident Title

• Investigation conducted on

  Date

• Prepared by

• Location
  Address

Section 1 - Where and When

• Date & Time of Incident

  Date
• Location of Incident
  Address

• Incident Type (select all that apply)

  Select Hazard Near-Miss Slip & Fall Accident Injury Theft Fire Property Damage Fatality Illness Reportable / Notifiable Loss Time Other

  • Hazard
  • Near-Miss
  • Slip & Fall
  • Accident
  • Injury
  • Theft
  • Fire
  • Property Damage
  • Fatality
  • Illness
  • Reportable / Notifiable
  • Loss Time
  • Other

• Please describe type of incident

Section 2 - Who

• Name of IOO/Employee

• Address
  Address

• Cell/ Phone Contact

• Name of on-duty supervisor at time of incident?

Section 3 - What (Incident Summary)

• Describe what happened. Please be detailed but state only facts.

Section 4 - Injury Information

• Incident Severity?

  Urgent

  High

  Medium

  Low

  Trivial

• Describe in detail what injurie(s) occurred. Please be detailed but state only facts.

  Yes

  No

  N/A

• Was medical attention administered?

  Yes

  No

• What kind of medical attention was administered?

  Select First Aid Doctor Consulted Hospital Ambulance Medical Attention Declined

  • First Aid
  • Doctor Consulted
  • Hospital
  • Ambulance
  • Medical Attention Declined

• Please detail medical attention

• Were the Police required?

  Yes

  No

• Was an Ambulance required?

  Yes

  No

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• Further action/follow-up/investigation required?

  Yes

  No

• Name of person/people to follow up

• Name & Signature of Investigator

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