Incident Report Form

Purpose: This form is intended to document workplace accidents, injuries, or any safety violations. It helps ensure proper follow-up, remediation, and compliance with company safety protocols.

Reporter Information

Name: {reporterName}

Position: {reporterPosition}

Department: {reporterDepartment}

Date of Report: {reportDate}

Incident Details

Date of Incident: {incidentDate}

Time of Incident: {incidentTime}

Location: {incidentLocation}

Description of Incident:
{incidentDescription}

People Involved

Injuries Sustained

{#hasInjuries}

• {injuredPerson}: {injuryDescription}

{/hasInjuries}

{^hasInjuries}No injuries were reported.{/hasInjuries}

Witness Statements

{#witnesses}

• {witnessName}: {witnessStatement}

{/witnesses}

Immediate Action Taken

{immediateAction}

Additional Notes

{additionalNotes}

Follow-Up Required

{#followUpRequired}Yes{/followUpRequired}

{^followUpRequired}No follow-up required.{/followUpRequired}

Supervisor Review

Reviewed By: {reviewerName}

Review Date: {reviewDate}

Comments:
{reviewComments}