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Workplace Incident Investigation Template

This Workplace Incident Checklist is a formal recording of the facts related to a workplace accident, injury, or near miss. Its primary purpose is to uncover the circumstances and conditions that led to the event in order to prevent future incidents.

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Reported details
Reported by
Date of report
Incident Number
Incident Information
Name of affected individual
Date of incident
Time of incident
Specific area of location
Additional personal involved
Extra Information
Incident description
Injuries, if any
Treatments required, if any
Other workers involved
Comments and Signature
Audit Signature
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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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