Title Page

  • Incident Numer

  • Date & Time of Incident

  • Reported By

  • Location


  • Name

  • Job Title

  • Store/Department

  • Work Address
  • Gender

  • Contact Number/Email

Alleged Offender(s)

  • Do you know the person(s) responsible?

  • Specify Name(s)

  • Approximate age

  • Gender

  • Relationship to the victim/reporting employee

Details of the Incident

  • Type of Incident

  • Description of Incident

  • Description of any injury, illness or property damage

  • Take/ upload photo evidence of incident, environment, person(s) involved

  • Date reported to regulatory authority


  • Observations and comments

  • Name & signature of person reporting

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.