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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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Workplace Incident Investigation Template

Reported details

Reported by

Title/Role

Date of report

Phone

Email

Incident Number

Incident Information

Name of affected individual

Location

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

Comments

Audit Signature

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