WORKPLACE INCIDENT REPORT FORM

Report Number: [AUTO-GENERATED]
Date of Report: [DATE]
Time of Report: [TIME]
Reported by: [NAME & POSITION]

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SECTION 1: INCIDENT DETAILS

Date of Incident: [DATE]
Time of Incident: [TIME] (24-hour format)
Location of Incident: [SPECIFIC LOCATION/BUILDING/ROOM]
Department/Area: [DEPARTMENT]
Shift: □ Day □ Evening □ Night □ Weekend
Weather Conditions (if relevant): [CONDITIONS]
Lighting Conditions: □ Adequate □ Poor □ Dark

SECTION 2: INCIDENT CLASSIFICATION

Type of Incident (Check all that apply):
□ Injury requiring first aid only
□ Injury requiring medical treatment
□ Injury resulting in lost time
□ Near miss (no injury occurred)
□ Property damage
□ Environmental incident/spill
□ Security incident
□ Fire/explosion
□ Chemical exposure
□ Vehicle incident
□ Other: [SPECIFY]

Severity Level:
□ Minor (first aid treatment only)
□ Moderate (medical treatment required)
□ Serious (hospitalization required)
□ Critical (life-threatening)
□ Fatal

SECTION 3: INJURED PERSON(S) INFORMATION

Primary Injured Person:
Name: [FULL NAME]
Employee ID: [ID NUMBER]
Position/Job Title: [TITLE]
Department: [DEPARTMENT]
Age: [AGE]
Gender: □ Male □ Female
Experience in current role: [YEARS/MONTHS]
Employment status: □ Employee □ Contractor □ Visitor □ Other

Contact Information:
Phone: [PHONE NUMBER]
Address: [HOME ADDRESS]
Emergency Contact: [NAME & PHONE]

Additional Injured Persons:
Name: [NAME] - Injury: [DESCRIPTION]
Name: [NAME] - Injury: [DESCRIPTION]

SECTION 4: DETAILED INCIDENT DESCRIPTION

What happened? (Describe the sequence of events leading to the incident):
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What was the injured person doing at the time of the incident?
_________________________________________________________________
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What equipment, tools, or materials were involved?
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SECTION 5: INJURY DETAILS

Part of body injured (check all that apply):
□ Head/Skull □ Face □ Eyes □ Neck □ Back □ Chest
□ Shoulder □ Arms □ Hands □ Fingers □ Abdomen
□ Legs □ Knees □ Feet □ Toes □ Internal □ Multiple

Nature of injury (check all that apply):
□ Cut/Laceration □ Bruise/Contusion □ Sprain/Strain
□ Fracture/Break □ Burn (heat) □ Chemical burn
□ Eye injury □ Back injury □ Puncture wound
□ Crushing injury □ Amputation □ Concussion
□ Other: [SPECIFY]

Side of body affected:
□ Left □ Right □ Both □ Not applicable

SECTION 6: IMMEDIATE ACTIONS TAKEN

First Aid Provided:
□ Yes □ No
If yes, by whom: [NAME & QUALIFICATION]
Description of first aid: [DESCRIPTION]

Medical Treatment:
□ Yes □ No
Where: [HOSPITAL/CLINIC NAME]
Treating Physician: [DOCTOR NAME]
Treatment provided: [DESCRIPTION]

Work Area Actions:
□ Area secured/isolated
□ Equipment shut down/isolated
□ Hazard eliminated/controlled
□ Work resumed □ Work stopped
□ Photos taken □ Evidence preserved

SECTION 7: WITNESS INFORMATION

Witness 1:
Name: [FULL NAME]
Position: [TITLE]
Contact: [PHONE/EMAIL]
Brief statement: [WHAT THEY SAW]

Witness 2:
Name: [FULL NAME]
Position: [TITLE]
Contact: [PHONE/EMAIL]
Brief statement: [WHAT THEY SAW]

Additional witnesses: [LIST NAMES]

SECTION 8: CONTRIBUTING FACTORS

Equipment/Tools involved:
Equipment: [NAME/TYPE]
Condition: □ Good □ Fair □ Poor □ Defective
Last maintenance: [DATE]
Operator training: □ Adequate □ Inadequate

Personal Protective Equipment:
PPE required: □ Yes □ No
PPE being worn: □ Yes □ No □ Partially
If no, why not: [EXPLANATION]
PPE condition: □ Good □ Fair □ Poor
PPE adequate for hazard: □ Yes □ No

Environmental factors (check all that apply):
□ Poor lighting □ Excessive noise □ Extreme temperature
□ Poor weather □ Slippery surfaces □ Inadequate space
□ Poor housekeeping □ Obstructed view □ Other: [SPECIFY]

Human factors (check all that apply):
□ Inadequate training □ Lack of experience □ Fatigue
□ Rushing/time pressure □ Improper procedure
□ Horseplay □ Under influence □ Medical condition
□ Other: [SPECIFY]

SECTION 9: ROOT CAUSE ANALYSIS

Immediate causes (unsafe acts/conditions):
1. [IMMEDIATE CAUSE]
2. [IMMEDIATE CAUSE]
3. [IMMEDIATE CAUSE]

Basic causes (management system failures):
1. [BASIC CAUSE]
2. [BASIC CAUSE]
3. [BASIC CAUSE]

Root causes (organizational factors):
1. [ROOT CAUSE]
2. [ROOT CAUSE]

SECTION 10: CORRECTIVE ACTIONS

Immediate actions (to prevent recurrence):
Action: [SPECIFIC ACTION]
Responsible Person: [NAME]
Target Date: [DATE]
Status: □ Pending □ In Progress □ Complete

Short-term actions (within 30 days):
Action: [SPECIFIC ACTION]
Responsible Person: [NAME]
Target Date: [DATE]
Status: □ Pending □ In Progress □ Complete

Long-term actions (within 90 days):
Action: [SPECIFIC ACTION]
Responsible Person: [NAME]
Target Date: [DATE]
Status: □ Pending □ In Progress □ Complete

SECTION 11: INVESTIGATION TEAM

Lead Investigator: [NAME & POSITION]
Team Members:
• [NAME & POSITION]
• [NAME & POSITION]
• [NAME & POSITION]

Investigation Date: [DATE]
Report Completion Date: [DATE]

SECTION 12: MANAGEMENT REVIEW

Reviewed by: [MANAGER NAME]
Position: [TITLE]
Date: [DATE]
Comments: [MANAGEMENT COMMENTS]

Follow-up Required: □ Yes □ No
Follow-up Date: [DATE]

SECTION 13: REGULATORY REPORTING

Reportable to authorities: □ Yes □ No
If yes, which authority: [AGENCY NAME]
Date notified: [DATE]
Reference number: [REFERENCE]
Report submitted by: [NAME]

SECTION 14: LESSONS LEARNED

Key lessons from this incident:
1. [LESSON LEARNED]
2. [LESSON LEARNED]
3. [LESSON LEARNED]

Communication plan:
□ Safety meeting □ Newsletter □ Training update
□ Procedure revision □ Toolbox talk
□ Other: [SPECIFY]

SECTION 15: COST INFORMATION

Medical costs: $[AMOUNT]
Property damage: $[AMOUNT]
Lost time costs: $[AMOUNT]
Investigation costs: $[AMOUNT]
Total estimated cost: $[TOTAL]

SECTION 16: SIGNATURES

Report Prepared by: _________________ Date: _______
[NAME & POSITION]

Injured Person: ____________________ Date: _______
[NAME] (if able to sign)

Supervisor: _______________________ Date: _______
[NAME & POSITION]

Safety Manager: ___________________ Date: _______
[NAME & POSITION]

Department Manager: _______________ Date: _______
[NAME & POSITION]

DISTRIBUTION:
□ Safety Department
□ Human Resources
□ Department Manager
□ Senior Management
□ Insurance Company
□ Regulatory Authority (if required)
□ Employee File

Document Control:
Form Version: 4.0
Form ID: IR-001
Last Updated: [DATE]
Retention Period: 7 years

CONFIDENTIALITY NOTICE:
This report contains confidential information and should be handled 
according to company privacy policies and applicable regulations.

NOTES/ADDITIONAL INFORMATION:
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