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Employee Relations
Incident Report Form
A form for documenting workplace incidents including accidents, injuries, near-misses, property damage, or security events with root cause and preventive measures.
INCIDENT REPORT FORM
Reported by: [Name]
Date of Report: [Date]
INCIDENT DETAILS
Date of Incident: [Date]
Time of Incident: [Time]
Location: [Location]
Type: ☐ Accident ☐ Injury ☐ Near-miss ☐ Property Damage ☐ Security ☐ Other
DESCRIPTION
Provide a factual account of what happened:
[Detailed description — what occurred, how, and circumstances]
PEOPLE INVOLVED
Name | Role | Statement Collected?
[Name] | [Employee/Witness] | ☐ Yes ☐ No
[Name] | [Employee/Witness] | ☐ Yes ☐ No
[Name] | [Employee/Witness] | ☐ Yes ☐ No
INJURIES OR DAMAGE
Injuries sustained: [Description, if any]
Medical attention required: ☐ Yes ☐ No
Property damage: [Description, if any]
Estimated cost: [Amount]
IMMEDIATE ACTION TAKEN
[What was done at the time — first aid, containment, reporting]
ROOT CAUSE (if known)
[What caused the incident]
PREVENTIVE MEASURES
[Recommended actions to prevent recurrence]
COMPLETED BY
Name: ___________________ Signature: ___________________ Date: _______
REVIEWED BY
Manager: ___________________ Date: _______
HR: ___________________ Date: _______
Safety: ___________________ Date: _______