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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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