Workplace Incident Report
SECTION 1: INCIDENT DETAILS
Company: ________________
Department: ________________ Supervisor: ________________
Date: ________________ Time: ________
Location: ________________________________
Severity: ________________
Description:
________________________________
Immediate Actions Taken:
________________________________
SECTION 2: POST-INCIDENT ACTIONS
Drug Test Required: ________
Workers' Compensation Filed: ________
SECTION 3: PEOPLE INVOLVED
SECTION 4: WITNESSES
No witnesses identified.
SECTION 5: ROOT CAUSE & CORRECTIVE ACTIONS
Contributing Factors:
________________________________
Root Cause:
________________________________
Corrective Actions:
________________________________
Preventive Measures:
________________________________
Follow-Up Date: ________