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Safety Incident Report Template

The document describes a safety incident report template that collects details about incidents including date, location, witnesses, category, injuries, immediate actions, contributing factors, investigations, preventive measures, and additional comments. It collects information to document, investigate, and prevent future incidents.

Uploaded by

Diego Matilla
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as XLSX, PDF, TXT or read online on Scribd
312 views3 pages

Safety Incident Report Template

The document describes a safety incident report template that collects details about incidents including date, location, witnesses, category, injuries, immediate actions, contributing factors, investigations, preventive measures, and additional comments. It collects information to document, investigate, and prevent future incidents.

Uploaded by

Diego Matilla
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd

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Safety Incident Report


INCIDENT DETAILS

Date and time of the incident :

Location of the incident :

Describe the incident :

Details of the witnesses, if any :

INCIDENT CATEGORY

Select the appropriate category for the incident:

Slip, Trip, or Fall

Equipment or Machinery Malfunction

Hazardous Material Exposure

Fire or Explosion

Personal Injury

Near Miss (incident with potential for harm but no actual injury)

Other (specify) :

PERSON(S) INVOLVED

Name(s) of the person(s) directly involved


in the incident
:

Job title(s) of the person(s) involved :

Describe the nature and extent of the


injuries, if any
:

Describe the treatments provided, if any :


IMMEDIATE ACTIONS TAKEN

Describe the immediate actions taken to :


address the incident and ensure safety

CONTRIBUTING FACTORS

Describe the immediate actions taken to address the incident and ensure safety

Inadequate training

Inadequate training

Unsafe work conditions

Human error

Lack of supervision

Communication breakdown

Other (specify) :

INVESTIGATION:

Will a further investigation be conducted? : ✘ YES NO

If yes, specify the person(s) responsible for


the investigation :

Provide any additional details or


instructions for the investigation :

PREVENTIVE MEASURES

What preventive measures can be :


implemented to avoid similar incidents in
the future?

ADDITIONAL COMMENTS

Is there any additional information or :


comments you would like to include?
REPORT FILTER

Name :

Job Title / Role :

Contact Details :

Template provided by:

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