Incident Report

Incident: An occurrence in the workplace that disrupts normal operations and has the potential to cause physical or psychological harm to individuals, the environment, or property.

Near Miss: A serious injury or illness narrowly avoided.

Contributing Factors: The multiple factors that may influence the occurrence of an incident, which, when identified and addressed, can prevent recurrence.

1. Reporter Details

Anonymous Report

NoYes

Reporter Name

Reporter Role

Other Role

Date and Time of Report

2. Incident Information

Brief Incident Description

Date and Time of Incident

Location of Incident

Other Location

Type of Report

Incident Severity

3. Who Was Involved

Number of Involved Person/s

Person 1 Name

Person 1 Role

Person 1 Involvement

Person 2 Name

Person 2 Role

Person 2 Involvement

Person 3 Name

Person 3 Role

Person 3 Involvement

Person 4 Name

Person 4 Role

Person 4 Involvement

Person 5 Name

Person 5 Role

Person 5 Involvement

4. Describe What Happened

Describe what happened (facts only)

Immediate Actions Taken After Incident

5. Type of Harm or Risk (tick all that apply)

Type of Harm or Risk

Other Harm or Risk

6. Impact and Severity

Actual Impact

Potential Severity if Circumstances were Different

7. Contributing Factors (tick all that apply)

Contributing Factors

Other Contributing Factors

8. Learning and Early Insights

Were there any early signs or warnings before the incident?

What helped prevent it from being worse (if anything)?

Suggestions to Prevent Reoccurrence

9. Follow-up and Notifications

Was your Supervisor Notified