Incident Report Template - Free Download
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Incident Report Template
Incident Report Template
Incident Reporting Form
Use this form to report any workplace accident, injury, incident, close call or illness.
Return completed form to the Operations Supervisor, or Management.
This is documenting an:
Lost Time/Injury First Aid Incident Close Call Observation
Details of person injured or involved (to be filled in by person injured / involved if possible)
Person Completing Report:_____________________ Date:____________________
Person(s) Involved:___________________________
Equipment or Truck ID:________________________
Event Details
Date of Event:_____________________ Location of Event:______________________
Time of Event:_____________________ Witnesses:___________________________
Description of Events (Describe tasks being performed and sequence of events):
_____________________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
*If more space is required please use the back of this sheet
Was event / injury caused by an unsafe act (activity or movement) or an unsafe
condition (machinery or weather) Please explain:
______________________________________________________________________
______________________________________________________________________
TO BE COMPLETED ONLY IF LOST TIME/INJURY OR FIRST AID WAS REQUIRED
Type of injury sustained:
Cause of lost time/ injury or
first aid:
Was medical treatment
necessary
Yes_____ No_____
If yes, name of hospital or physician:
Signature of Employee:_____________________________ Date:__________________
Signature of Supervisor:____________________________ Date:__________________
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source: fwsn.org
Incident Report Template
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