Incident Report Form

Project Name: ...............................................................................................

Project Location: ..........................................................................................

Report Date: ..................................................................................................

Reported By: ................................................................................................

Job Title: ......................................................................................................

Section 1: Incident Details

Incident Date: .......................................................................

Time of Incident: ..................................................................

Location of Incident: ............................................................

Type of Incident:

 Accident
 Near Miss
 Environmental Incident
 Property Damage
 Other (Specify): ______________

Description of Incident:
Provide a detailed description of the incident, including the sequence of events leading up to
it, what happened, and the immediate aftermath.

Section 2: Persons Involved

Name Job Title Contact Information Injury Details (if applicable)

[Name 1] [Title 1] [Contact Info 1] [Injury Details 1]
[Name 2] [Title 2] [Contact Info 2] [Injury Details 2]
[Name 3] [Title 3] [Contact Info 3] [Injury Details 3]
... ... ... ...

Section 3: Witnesses

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FORM ID: SIC-01/24
 Name Job Title Contact Information Statement Attached
[Name 1] [Title 1] [Contact Info 1] Yes / No
[Name 2] [Title 2] [Contact Info 2] Yes / No
[Name 3] [Title 3] [Contact Info 3] Yes / No
... ... ... ...

Section 4: Immediate Actions Taken

Actions Taken Immediately After the Incident:

[Detail any first aid provided, emergency services called, equipment shut down, etc.]

Section 5: Root Cause Analysis

Immediate Causes:
[Identify any immediate causes of the incident, such as equipment failure, human error,
environmental factors, etc.]

Underlying Causes:
[Identify any underlying causes, such as lack of training, inadequate procedures, poor
maintenance, etc.]

Section 6: Preventive Measures

Short-term Corrective Actions:

[List any actions taken to prevent a recurrence in the short term, such as repairs, temporary
changes in procedure, etc.]

Long-term Preventive Actions:

[List any actions planned to address the root causes and prevent future incidents, such as
training programs, policy changes, equipment upgrades, etc.]

Section 7: Incident Review and Sign-Off

Reviewed By: ________________________

Date: [Insert Date]

Project Manager's Comments:

[Include any comments or additional information from the project manager.]

Project Manager's Signature: ________________________

Date: [Insert Date]

2
FORM ID: SIC-01/24
Follow-Up Review Date: [Insert Date for Follow-Up Review]

3
FORM ID: SIC-01/24