Incident Report Form

Document Control Company: [COMPANY NAME] · Logo: [COMPANY LOGO] · Address: [COMPANY ADDRESS] Prepared by: [RESPONSIBLE PERSON] · Date: [DATE] · Approved by (signature): _________________

Field	Value
Category	Incident and Near Miss Reporting
Recommended Industry	All
Document Type	Form
Access Level	Starter
Last Reviewed	2026-06-29
Last Updated	2026-06-29

How to Use This Template

Complete this form as soon as it is safe to do so after any injury, illness, near miss, or property-damage event. Capture the facts objectively — what happened, not who to blame. Attach witness statements (use the Witness Statement Form) and photos (log them on the Photo Evidence Log). Route the completed form to the responsible person for review and corrective action, and retain it with your records. Reporting a near miss is encouraged and will not result in discipline for reporting.

1. Incident Information

Field	Entry
Date of incident:	[] Time: [] ☐ AM ☐ PM
Date reported:	[____] Reported to: [NAME]
Location / project:	[____]
Type:	☐ Injury/illness ☐ Near miss ☐ Property damage ☐ Vehicle ☐ Other: ____
Reported by:	[NAME / TITLE]

2. Person(s) Involved

Field	Entry
Name:	[] Job title: []
Employee ☐ Subcontractor ☐ Visitor ☐ Other: ____
Body part(s) affected (if any):	[____]
Task being performed:	[____]

3. Description of What Happened

[Describe the sequence of events factually and in order. Include tools/equipment/materials involved, conditions, and what the person was doing at the time. Continue on an attached page if needed.]

4. Contributing Conditions / Factors

Equipment / tools: [____]
Environment / weather / housekeeping: [____]
Procedures / training: [____]
PPE in use: [____]

5. Immediate Actions Taken

[First aid given, area secured, equipment removed from service, supervisor notified, emergency services called, etc.]

6. Witnesses

Name	Contact	Statement attached?
[____]	[____]	☐ Yes ☐ No
[____]	[____]	☐ Yes ☐ No

7. Initial Corrective Actions (to prevent recurrence)

Action	Responsible	Due Date	Completed
[____]	[NAME]	[DATE]	☐
[____]	[NAME]	[DATE]	☐

(For serious incidents, complete the Root Cause Analysis Form and Incident Investigation Checklist.)

8. Signatures

Role	Print Name	Date
Person involved (if able)	[____]	[DATE]
Supervisor	[____]	[DATE]
Safety / responsible person	[____]	[DATE]

Company Customization Needed

Insert your company information and your internal reporting timeline (e.g., "report within 24 hours").
Identify who receives this form and who is responsible for follow-up.
Confirm whether the event triggers OSHA recordkeeping (300/301) or reporting obligations for your company. Review and customize based on applicable federal, state, local, client, and project-specific requirements.
Keep medical details confidential and store per your recordkeeping and privacy practices.

Last Reviewed / Last Updated

Last Reviewed: 2026-06-29
Last Updated: 2026-06-29
Next Review Due: [SET DATE]

Disclaimer

This document is a general safety template and educational resource. It is not legal advice, does not replace a site-specific hazard assessment, and does not guarantee compliance with OSHA or any federal, state, or local requirement. Employers are responsible for reviewing, customizing, implementing, training employees on, and maintaining their own safety programs and records. Consult a qualified safety professional, legal counsel, or regulatory authority when needed.

_{Template ID: incident-report-form · Editable master (Markdown). Export to Word/PDF for distribution. Access level: Starter.}