Incident report form
A free, printable incident report form, a companion to our Learn page on how to write an incident report. Fill it in the same day, while the facts are fresh. No sign-up needed.
This form records the facts. To find out why it happened and stop it happening again, use the full Incident Report Template.
| Reference number | |
|---|---|
| Filled in by | |
| Date filled in |
1. What kind of incident
- Injury or ill health
- Near miss (close call): nobody was hurt, but someone could have been
- Damage to property, equipment or a vehicle
- Security incident: theft, a break-in, violence or threats
- Spill or leak
- Other: ____________________
2. When and where
| Date | |
|---|---|
| Time | |
| Exact location |
3. Who was involved
| Name | Employee, contractor, visitor or customer | Hurt? (yes / no) | Witness? (yes / no) |
|---|---|---|---|
4. What happened
Facts only: what you saw, heard and were told.
What was the person doing just before it happened?
What happened, step by step?
Any injury or damage, and what treatment was given?
5. Immediate action taken
- Injured person looked after, and emergency services called if needed
- Area made safe
- Photographs taken before anything was moved
- Equipment involved taken out of use
- Witnesses’ accounts written down
- Manager or owner told
6. Must anyone outside be told?
Some incidents must be reported to the authorities within days, or even hours: in the UK, to the Health and Safety Executive under RIDDOR; in the US, to OSHA. Check the same day.
- Checked whether this incident must be reported
- Reported to: ____________________ on (date) __________
7. Signed
| Name | Signature | Date | |
|---|---|---|---|
| Reported by | |||
| Received by (manager) |
Take it further
Plain Standards: plain-English ISO templates and unaccredited remote certification, built by a company director of over 30 years.
- Incident Report Template: the full report in Word: evidence, who must be told in the UK and US, three levels of cause, and actions checked until they work, with a worked example. plainstandards.com/products/incident-report-template
- Root Cause Analysis Template: for a serious or repeated incident, dig deeper into why it happened. plainstandards.com/products/root-cause-analysis-template
More free Learn pages and printables at plainstandards.com