Incident Report
Incident Type


First Aid

Automotive or field equipment

Near Miss


Exact Description of Occurence

According to you what was the unsafe situation or action?

What are the preventive and corrective procedures?

Witness of incident

Name of witness

Are instructions been given before starting the job?

Is Medical Treatment required?

Name of Clinic or Hospital

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.