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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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