Title Page

  • Name

  • Current Date & Time

Personal Information

  • Phone Number

  • Street

  • City

  • State

  • Zip

  • Position

  • What time did you start your shift?

  • # of days since last day off

Incident Details

  • What type of accident are you reporting?

  • Other

  • When did the incident occur?

  • Who did you report the incident to?

  • When did you report the incident?

  • Describe the incident. Please be specific.

  • How could the incident be prevented?

  • Location incident occured

  • Other

  • Are there any witnesses?

  • If yes, please provide a name and contact number. If no, mark NA.

  • Did adverse conditions (noise, light, traffic, etc.) impact this incident?

  • If yes, please describe. If no, mark NA.

  • Hazardous Material Spill?

  • Equipment #. Mark 0 for NA

  • Describe any damages

  • Was another person involved in the incident?

  • If yes, please list name & contact number. If no, mark NA.

Media

  • Add any pictures here.

  • Sketch the incident.

Employee Signature: By signing below, you certify that the information provided in this report is a true and correct statement of the facts and that you made such statement of you own free will.

  • Employee

Supervisor Signature: By signing below, you verify that you have reviewed the incident with the employee.

  • Supervisor

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.