Safety Incident Report Form

Safety Incident Report

* Indicates required field

Date *

Time *

Witness name *

Job Title *

Phone *

Background information *

Location of incident *

Did the incident result in injuries? *

Yes No

If yes, list injured persons (name - position) *

Did the incident result in damage to property? *

Yes No

If yes, list damage *

Description of incident *

What causal factors were involved? (e.g., lack of policy, lack of training, unsafe act, broken machinery, procedure, etc.) *

What corrective actions are being taken to prevent it from happening again, if any? *

Submitted by - Name *

Job Title *

Phone *

Submit