Title Page

  • Conducted on

  • Prepared by

  • Location

About the Person & Injury

  • Date and Time of the Incident

  • Name of Injured Person

  • Injured Person's Department

  • Location Injury Took Place

  • Location if not listed in dropdown options

  • Location on body of injury

  • Exact location of injury - Example - left hand index finger

  • Type of injury

  • If Injury Type is not listed, please give details below

  • Attach photos of the injury - ensure permission is granted from the injured person before this is done

About the Incident

  • Please provide as much detail as possible about the incident which has caused the injury. Ensure the information entered is factual and not an opinion.

  • Give details of how the accident occurred - ensure this is the information provided to you by the inured person

  • where there any witnesses to the incident?

  • Provide names of witnesses

  • Provide the type of first aid treatment given

  • Location of injured person

  • Provide photos of the location of the incident

Sign off

  • Has the injured persons Line / Direct Manager been informed?

  • First Aider

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.