Incident Report Form Template

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Incident Report Form Template

Hazard and Incident Details

Incident Category

Select Injury/ Illness Property Damage Near Hit Hazard Risk Other

1. Injured Person (if applicable)

Take a photo of the injured person (where appropriate)

Add Photo

Full Name

Date of Birth

Select date

Sex

Male Female

Contact Number/ Email

2. Job Details (if applicable)

Job Title

How long in this occupation?

Start time

Select date

Total Hours worked

8 hours or less More than 8 hours

Shift arrangement

Fixed shift Rotating shift

Training/ Qualifications

Select Injury/ Illness Property Damage Near Hit Hazard Risk Other

3. Hazard/ Incident Details

Time of incident

Select date

Reported

Select date

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

Add Photo

Date reported to regulatory authority (only if required)

Select date

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.