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Incident Report Form

This incident report form is used to document all incidents, especially those involving death, serious injury, major property damage, or media interest. The form collects details of the incident, those involved, treatment provided, witnesses, corrective actions taken, and acknowledges completion of the report. Major incidents must be reported to the General Manager immediately and all reports forwarded within 24 hours.

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Avril Cervantes
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135 views3 pages

Incident Report Form

This incident report form is used to document all incidents, especially those involving death, serious injury, major property damage, or media interest. The form collects details of the incident, those involved, treatment provided, witnesses, corrective actions taken, and acknowledges completion of the report. Major incidents must be reported to the General Manager immediately and all reports forwarded within 24 hours.

Uploaded by

Avril Cervantes
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Incident Report Form

 All major incidents involving - death, serious injury, major property damage, and media interest - contact the
General Manager immediately, then complete Incident Report & forward ASAP.
 Incident Reports must be completed for all other incidents within 24 hrs. & forwarded to the GM and HR, if staff
related.
Part 1: INCIDENT DETAILS
 Personal Injury  Near Miss  Environmental  Property Loss/Damage
Incident

 Other (provide detail)

Area

Date Time

Name of Injured Person

D.O.B. Gender □ Male □ Female

Address

Telephone

Identify as  Guest/Visitor  Employee ID No.:


Occupation/Department:

 Contractor  Other (provide detail)

Incident Description 
[Location/Type/Nature/ 
Conditions]

Injured Person to Sign


(if possible)

Description of injury/ or
Environmental/ Property
damage

Photos of Scene/Damage □ YES □ NO

Was appropriate □ YES □ NO


Protective clothing worn?
Detail

ff Was the staff trainer for □ YES □ NO


the job?

Machinery/Tools □ YES □ NO
Involve details
Incident Report Form
Part 2: MEDICAL DETAILS
Treatment Details

Who Provided Treatment

Treatment Provided  First Aid Only  Incident/Near Miss/No Injury 


 Hospital/Medivac/Ambulance Medical Practitioner
 Fire Department  Other

Transportation Type  Ambulance  Helicopter  Boat  Other

Part 3: REPORT COMPLETION DETAILS/ ACKNOWLEDGEMNT


Who was Incident reported to? Time Reported

Method Incident was  In Person  Telephone  In Writing  Other


Reported

Report Completed By

Position

Signature Date

Part 4: WITNESS DETAILS


Witness Name D.O.B.

Address

Telephone

Describe Relationship to Third


Party (if any)

Description of Incident by
the Witness

Witness to Sign Date

Part 5: CORRECTIVE ACTONS/CONTROLS IMPLEMENTED


Short Term: Responsible Person(s)
Incident Report Form
Long Term: Responsible Person(s)

Maintenance Job Logged [if required]

CHECKLIST:
Task Completed Date Completed

Incident Report Form provided to site GM / HR □ Yes □ No


Manager if relevant to staff

GM to contact HEAD OFFICE in case of death, □ Yes □ No


media interest, serious property damages

HR – Follow up with informing family of staff □ Yes □ No


concerned

* Please attach additional sheets with any further relevant information or documents,

photographs ADDITIONAL COMMENTS:

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

_______

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