Lumiform / Templates / Incident Report Form Template

Incident Report Form Template

An incident reporting form helps safety officers to prepare and submit incident reports. Use the data collected from incident reports to identify the common causes of work-related incidents and to determine how to reduce risk.

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Incident Report Form Template

Hazard and Incident Details

Incident Category

1. Injured Person (if applicable)

Take a photo of the injured person (where appropriate)

Full Name

Date of Birth

Sex

Contact Number/ Email

2. Job Details (if applicable)

Job Title

How long in this occupation?

Start time

Total Hours worked

Shift arrangement

Training/ Qualifications

3. Hazard/ Incident Details

Time of incident

Reported

Specific Location of incident

Description of hazard incident

Description of injury, illness or property damage

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

Date reported to regulatory authority (only if required)

4. Witness Statements (if applicable)

Full Name

Contact

Statement

Witness signature (if applicable)

5. Completion

Further comments

Full Name and signature of reporting person

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Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.

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Employee Incident Report

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This template helps you record workplace incidents that have resulted in an injury or illness. Fill it out immediately after an onsite incident or near miss occurs.

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