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Workplace Incident Report

Report Date: [incident_date_display]

State: [_state_name]

[_osha_recordable_label]

[_critical_incident_label]

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: ________

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