Incident Reporting Form
Date of Incident
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Incident
*
Location of Incident
*
Report Completed By
Name
*
First Name
Last Name
Email
*
example@example.com
Position
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
*
Individuals Involved
Names
*
Roles
Victim, Witness, etc.
Email(s) and Phone Number(s)
Incident Description:
Type of Incident
*
Injury
Property Damage
Near Miss
Harassment
Unsafe Condition
Other
Please provide a detailed description of the incident, including events leading up to it, actions taken during the incident, and any relevant details.
*
Was anyone injured?
*
Yes
No
Describe who was injured, the injuries, and details of the treatment supplied or required.
What actions were taken immediately after the incident? Were emergency services contacted?
*
Follow-Up Action Needed: Do you recommend any follow-up actions to prevent a recurrence or to address any outstanding issues related to the incident?
*
Yes
No
Please specify recommended follow-up actions.
Submit
Should be Empty: