Information

  • Document No.

  • Report Title

  • Jobsite

  • Conducted on

  • Prepared by

GENERAL INFORMATION

  • TYPE OF INCIDENT

  • DATE AND TIME OF INCIDENT

  • DATE AND TIME REPORTED

  • JOBSITE

  • LOCATION OF INCIDENT

INCIDENT OBSERVATIONS

  • WHAT DID YOU OBSERVE AT THE INCIDENT SITE?

  • WHAT DID YOU DO DURING/AFTER THE INCIDENT?

  • WHY DID THE INCIDENT OCCUR?

  • WHY DID THE ACCIDENT OCCUR? (IF APPLICABLE)

  • WHAT ACTIONS HAVE OR WILL BE TAKEN TO PREVENT RE-OCCURRENCE?

CERTIFY

  • SUPERVISOR'S SIGNATURE

  • SAFETY COORDINATOR'S 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.