INCIDENT #

Incident Report Form

Instructions: Please complete this form in its entirety within 12 hours of the incident.

Type of Incident:
□
□ Injury □ Property Damage
□ Illness □ Theft
□ Accident
□ Other
Please explain:

Date of Incident: Time of Incident:

Location of Incident:
Reported by (Name and Position):

NAME AND CONTACT DETAILS OF PERSON/S INVOLVED:

1.
2.
3.
NAME AND CONTACT DETAILS OF WITNESS/ES:
1.
2.
3.
Incident description including any events leading to or immediately following the incident:

Was the incident caused by an unsafe act (activity, movement or an unsafe condition (machinery or weather))?
Employee Signature and Date Supervisor Signature and Date