• Conducted on

  • Prepared by

Incident information

  • Site:

  • Time and date of incident:

  • Location of incident

  • What type of incident occurred?

Patient details:

  • Patient name:

  • Patient age approx:

  • Patient (or guardian) address and contact ph #:

Injury description:

  • What type of injury?

  • Details of condition if any: (eg medication)

  • Area of injury? e.g. Left Knee

  • Cause of injury:

Event log and action taken:

  • Ambulance called? (if yes include ambulance number and destination)

  • Was first aid administered? (if so explain treatment)

  • Log of events including times and persons involved:

  • Was this injury caused by environmental issues? E.g trip hazard

  • Multiple pictures of area:

  • What action has been taken to rectify this issue? (e.g cones placed) ACTION MUST BE TAKEN.

  • Picture of area injury occurred.

Fire Incident details:

  • Was this a real fire? Confirmed and not a false alarm.

  • Were any injuries caused by this fire?


  • Did the fire panel/fire alarm trigger? List zones.

  • Was the fire department called? (If yes include time on site and fire dept action taken)

Action taken:

  • Log of events including times and persons involved:

  • Did you use any fire fighting equipment? Note what equipment and how. (if extinguishers were used log location taken and picture of equipment)

  • Photo of area/damage:

  • There is no real fire and this is a confirmed false alarm.

  • Did the fire panel activate? Picture of panel and describe location:

Action taken:

  • Was a full check of the zone in alarm/fault conducted?

  • What was deemed the cause of this activation/fault?

  • Actions taken: (eg, isolate the zone, call base etc)

  • Photo of the faulty/in alarm activator:

  • Was first aid applied to any persons involved?


  • Were restraints used in this incident? If yes explain why.

  • Did police attend site? List time/action taken.

  • Log of events:

  • Name and contact number of victim:

  • Description and estimated price of item stolen:


  • Was the offender caught? If yes, add photo.

  • Is there CCTV footage of the theft? If yes, add times and camera numbers.


  • Gender:

  • Clothing:

  • Define colour, briefly:

  • Last known location:

  • Log of events:

  • Type of incident:

  • Log of events:

  • Any media:


  • Additional notes:

  • At the time of completing this report no further information was available to me.

  • Full 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.