Incident Report

Incident Report
Initial Details
To be completed in the event of an incident, a major non-conformance, unsafe practice or a near miss that could have resulted in a serious injury or illness.
YesNo (If No, you must complete the 'Near Miss Report' not this 'Incident Report')
Who had the incident?
EmployeeNon-Employee
Person involved in incident:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Yes - Continue to next sectionNo - Enter reporter details below
Reporter Details:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
About the Incident

Where did the near miss occur?
Site Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
When did the Incident happen?

DayMonthYear
Date
Time
What Happened?
First Aid

Provide details below
Was First Aid given? If Yes, provide details below:
Were there any other person/s involved in the incident? If yes, provide details.
Were there any witnesses to the incident? If yes, provide details.
YesNo
Has the incident site been made safe? If yes, provide details of action taken.
Photo of damage, hazard, solution or Injury:

Cancelof
Additional Information:
Should be Empty:

Who had the incident?