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Health and safety incident report form

Health and safety incident report form

Document workplace accidents, injuries, or near-misses in detail with this report form. Ensure accurate reporting, identify root causes, and enhance compliance.

Use this template with Lumiform

The Lumiform application helps frontline teams uphold internal standards effortlessly.
  • Customize this template or build your own
  • Fill out templates via mobile app
  • Assign and track corrective actions
  • Get reports and analyse your data
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Health and safety incident report form

Document workplace accidents, injuries, or near-misses in detail with this report form. Ensure accurate reporting, identify root causes, and enhance compliance.

Use this template with Lumiform

The Lumiform application helps frontline teams uphold internal standards effortlessly.
  • Customize this template or build your own
  • Fill out templates via mobile app
  • Assign and track corrective actions
  • Get reports and analyse your data
Prices start from ░░░ per month
Book a demo
Learn more
or Download template as PDF

A health and safety incident report form template allows you to document workplace incidents accurately and comprehensively. This template captures critical details from incident timing and location to injury specifics and witness statements, ensuring you have a thorough record during stressful situations.

According to Gallup research, nearly one in five workers worldwide have suffered serious workplace harm in the past two years, with almost half of these incidents going unreported. This template helps you break that cycle by making thorough documentation straightforward and accessible.

Related categories

  • Health and safety management templates
  • General templates
  • Inventory management templates
  • Workplace safety templates
Preview of the template
Page 1
Incident Details
Date of Incident
Location of Incident
Incident Description
Injured Person Details
Name of Injured Person
Age
Gender
Contact Number
Address
Incident Type
Type of Incident
Briefly Describe Incident Type
Injury Details
Type of Injury
Body Part Affected
Severity of Injury
Witness Details
Witness Name
Witness Contact Number
Witness Statement
Corrective Actions
Immediate Actions Taken
Preventive Measures
Reporting Details
Reported By
Reporting Date
Supervisor Name
Supervisor Signature

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Related resources

Access a complete set of resources aimed at maximizing safety, quality, and operational excellence, including detailed guides, related templates, and real-world use cases.

Topic guides

Read in-depth guides covering key topics related to this article.

Occupational health and safety: A comprehensive guideHow to write an incident report: Your complete guideIncident management: A deep dive
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Template collections

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10 powerful free health and safety policy templates4 free workplace incident report templates6 free health and safety risk assessment templates
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Use cases

Check out how the Lumiform software can be utilized for related use cases.

Health and safety management system softwareIncident report softwareOccupational health and safety softwareIncident management software
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Other resources

Explore all the additional resources we offer to assist you in mastering this topic.

5 types of incident reports10 reasons why workplace safety is importantHow to perform safety inspections4 benefits of safety management and how to communicate them

Frequently asked questions

How can I ensure my incident report forms are completed accurately?

Focus on timing—complete forms within 24 hours while details are fresh. Train staff to use objective language, include photos when possible, and implement a review process where supervisors verify information. Creating a culture where thorough reporting is valued rather than rushed will naturally improve accuracy.

What should I do if witnesses give conflicting accounts of an incident?

Document all perspectives without judgment, noting specific discrepancies. Interview witnesses separately to avoid influence, and ask clarifying questions about their vantage point and attention at the time. Physical evidence and workplace cameras can help resolve contradictions. Remember that perception varies naturally—conflicts don’t necessarily indicate dishonesty.

How do I determine the severity level of an injury on this incident report form?

Consider factors like medical attention required, work time lost, and long-term impact. “Minor” typically means first-aid only with no lost time, “moderate” involves medical treatment beyond first aid, while “serious” indicates hospitalization, significant lost time, or permanent effects. When in doubt, consult with medical professionals rather than downplaying severity.

What are the most common mistakes people make when filling out incident report forms?

Vague descriptions top the list—”employee fell” versus “employee slipped on oil spill near machine #4.” Other common errors include delayed reporting, omitting witness information, speculating about causes rather than reporting facts, and rushing through corrective action plans without proper analysis of root causes.


This template, developed by Lumiform employees, serves as a starting point for businesses using the Lumiform platform and is intended as a hypothetical example only. It does not replace professional advice. Companies should consult qualified professionals to assess the suitability and legality of using this template in their specific workplace or jurisdiction. Lumiform is not liable for any errors or omissions in this template or for any actions taken based on its content.
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