Safety Incident Report

Purpose: This document serves to record and analyze workplace safety incidents or accidents. It is used to identify hazards, determine root causes, document injuries or damages, and outline corrective actions to prevent future occurrences.

Incident Information

Date of Incident: {incidentDate}

Time of Incident: {incidentTime}

Location: {location}

Reported By: {reportedBy}

Persons Involved

Incident Description

Summary:

{incidentSummary}

Cause Analysis

Immediate Cause(s): {immediateCauses}

Root Cause(s): {rootCauses}

Witness Statements

{#witnesses}

• {name}: {statement}

{/witnesses}

Actions Taken

Initial Actions: {initialActions}

Medical Attention Provided: {#medicalProvided}Yes{/medicalProvided}{^medicalProvided}No{/medicalProvided}

Authorities Notified: {#authoritiesNotified}Yes{authorityDetails}{/authoritiesNotified}{^authoritiesNotified}No{/authoritiesNotified}

Corrective & Preventive Actions

{#correctiveActions}

• {action}: Responsible: {responsible}, Due Date: {dueDate}

{/correctiveActions}

Follow-Up & Verification

Follow-Up Date: {followUpDate}

Verified By: {verifiedBy}

Verification Notes: {verificationNotes}

Additional Information/Notes

{additionalNotes}