INCIDENT REPORT FORM

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

SECTION 1: INCIDENT DETAILS

Date of Incident: [DATE]
Time of Incident: [TIME]
Location of Incident: [SPECIFIC LOCATION]
Department/Area: [DEPARTMENT]
Shift: [DAY/EVENING/NIGHT]
Weather Conditions (if relevant): [CONDITIONS]

SECTION 2: INCIDENT CLASSIFICATION

Type of Incident (Check all that apply):
□ Injury (requiring first aid)
□ Injury (requiring medical treatment)
□ Injury (lost time)
□ Near miss
□ Property damage
□ Environmental incident
□ Security incident
□ Fire/explosion
□ Chemical spill
□ Other: [SPECIFY]

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

SECTION 3: INJURED PERSON(S) INFORMATION

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

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

SECTION 4: INCIDENT DESCRIPTION

Describe what happened (be specific and factual):
[Detailed description of the incident sequence]

What was the injured person doing at the time?
[Activity being performed]

What part of the body was injured?
□ Head/Face □ Eyes □ Neck □ Back □ Chest
□ Arms □ Hands □ Fingers □ Legs □ Feet
□ Internal □ Multiple □ Other: [SPECIFY]

Nature of injury:
□ Cut/Laceration □ Bruise/Contusion □ Sprain/Strain
□ Fracture □ Burn □ Chemical exposure □ Eye injury
□ Back injury □ Other: [SPECIFY]

SECTION 5: IMMEDIATE ACTIONS TAKEN

First Aid Provided: □ Yes □ No
By whom: [NAME & QUALIFICATION]
Medical Treatment: □ Yes □ No
Where: [HOSPITAL/CLINIC NAME]
Treating Physician: [DOCTOR NAME]

Work Area Secured: □ Yes □ No
Equipment Isolated: □ Yes □ No □ N/A
Photos Taken: □ Yes □ No
Evidence Preserved: □ Yes □ No

SECTION 6: WITNESSES

Witness 1:
Name: [NAME]
Position: [TITLE]
Contact: [PHONE/EMAIL]
Statement: [BRIEF STATEMENT]

Witness 2:
Name: [NAME]
Position: [TITLE]
Contact: [PHONE/EMAIL]
Statement: [BRIEF STATEMENT]

SECTION 7: CONTRIBUTING FACTORS

Equipment/Tools involved:
[LIST EQUIPMENT]

Condition of equipment: □ Good □ Fair □ Poor □ Unknown
Last maintenance date: [DATE]
PPE being used: □ Yes □ No
If no, why not: [EXPLANATION]
PPE adequate: □ Yes □ No □ N/A

Environmental factors:
□ Poor lighting □ Noise □ Weather □ Temperature
□ Housekeeping □ Space constraints □ Other: [SPECIFY]

Human factors:
□ Inadequate training □ Fatigue □ Rushing
□ Improper procedure □ Lack of experience
□ Other: [SPECIFY]

SECTION 8: ROOT CAUSE ANALYSIS

Immediate causes (unsafe acts/conditions):
[LIST IMMEDIATE CAUSES]

Basic causes (management system failures):
[LIST UNDERLYING CAUSES]

SECTION 9: CORRECTIVE ACTIONS

Immediate actions (to prevent recurrence):
Action: [SPECIFIC ACTION]
Responsible Person: [NAME]
Target Date: [DATE]
Status: [PENDING/COMPLETE]

Long-term actions:
Action: [SPECIFIC ACTION]
Responsible Person: [NAME]
Target Date: [DATE]
Status: [PENDING/COMPLETE]

SECTION 10: INVESTIGATION TEAM

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

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

SECTION 11: MANAGEMENT REVIEW

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

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

SECTION 12: REGULATORY REPORTING

Reportable to authorities: □ Yes □ No
Authority notified: [AGENCY NAME]
Date notified: [DATE]
Reference number: [REFERENCE]

SECTION 13: LESSONS LEARNED

Key lessons from this incident:
[LESSONS LEARNED]

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

SIGNATURES

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

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)

Document Control:
Form Version: 2.0
Form ID: IR-001
Last Updated: [DATE]