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1. Incident Report Form
Purpose
This is an Incident Report Template, which can be customized and used to report events that
occur on site.
Name:
Date of Incident: Time of Incident:
Date of Report: Employee / Visitor (circle one)
Daytime Phone Number: Evening Phone Number:
Describe the incident:
Location of Event: Were you injured: Yes / No (circle one)

2. (Please circle the areas of the body involved in the
incident):
Write a Description of the Injury:
What factors contributed to the event?
How could the event have been avoided?
Was First aid administered? YES / NO If yes, by whom?
Signature of Injured Party:
Complainant Date:
INJURED PARTY/COMPLAINANT TO COMPLETE, SIGN, DATE & SUBMIT to
your immediate supervisor/department within 24 HOURS of the event.
If form completed by someone other than the injured party, please fill out the following lines:
Form Completed by:
Telephone Number:

3. Signature Date:
The IMMEDIATE SUPERVISOR IS TO COMPLETE, SIGN, DATE & SEND hard
copy to the Corporate Office. IF an injury occurred, SEND a copy to Benefits Office.
Supervisor’s Name:
Date of Incident: Time of Incident:
Date of Report: Supervisor’s Position:
Daytime Phone Number: Evening Phone Number:
If there was a delay in reporting this event, list reason(s):
Material Damage: YES / NO Approximate Value:
Cause of event – List Root Causes:
What corrective actions are being taken to prevent recurrence?
Has a risk assessment been carried out for the process/activity? YES NO
Have person(s) involved received training or instruction in the work or activity being carried out?
YES / NO

4. Was there any supervision of the work or activity being carried out? YES / NO
Supervisor’s Comments (Additional information on event):
If injury occurred, please check one:
o No First-Aid administered, returned to work
o First-Aid administered, returned to work
o Saw a physician, returned to work
o Saw a physician, returned to light duty
o Saw a physician, time loss
o Refused medical treatment
Supervisor’s Signature:
Date:
Section C: General Information
Distribution: Risk Management Benefits Office, HR Department, Department Head, Senior
Management.
Follow-Up: Injured Party, Supervisor and Department Head
Other ____________ Other ____________