Incident report form

Job: ___officer____Date of incident: __16_/__09__/__21_Time __1.30___/pm

1. What was the Incident/near miss?

There has been an emergency incident in the kitchen. A small fire has damaged a cupboard and
a few cooking pots are destroyed

2. Where there any injuries? (Note: Any injuries require an Accident Report Form)

In In the kitchen

3. Was there any damage to property or plant?

Aaa cupboard and cooking pots are destroyed
 Incident report form

4. What caused the incident?

A A small fired

5. What actions will be taken to eliminate future repeats of the incident?

The officer ask her co-worker for get rid of the small fire
Report incident to the manager for the prevent in the future

6. Management comments
It would have been an evaluation on the situation and communication on the future plan

Signed off by management when corrective actions have been adopted and monitored.

Management signature___________________ Date of sign off_________________