Workplace Incident Report

Captures the facts of a workplace injury, illness, or near-miss. Feeds OSHA 301 / 300 logs and workers' compensation claims. Designed to be filed within 24 hours of the incident.

Report Overview

• Date of incident
  Select the date the incident occurred.
• Time of incident
  Enter the approximate time the incident occurred.
• Date reported
  Select the date this report is being submitted.
• Type of incident
  Choose the option that best describes what happened.
• Reporter role
  Select your relationship to the incident.
• Brief incident summary
  Describe what happened in 1-3 sentences. Focus on observable facts, not opinions.

Affected Person

• Affected person type
  Select who was affected by the incident.
• Affected person name
  Enter the person's name if known. Leave blank for anonymous or unknown reports.
• Department / team
  Enter the department or team, if applicable.
• Job title / role
  Enter the person's job title or role, if applicable.
• Primary work location
  Enter the person's usual work location if relevant to the incident.

Incident Details

• Incident location
  Enter the specific area, site, or room where the incident occurred.
• Incident address
  Enter the site address if the incident occurred offsite or at a location not already known.
• Activity at time of incident
  Describe what the affected person was doing immediately before the incident.
• What contributed to the incident?
  Select all factors that may have contributed. Use only observable facts.
• Detailed description
  Provide a factual narrative of what happened, including sequence of events and any immediate observations.

Injury or Illness Details

• Body part affected
  Select all body parts affected, if known.
• Injury or illness description
  Describe the injury or illness symptoms using observable facts.
• Medical treatment provided
  Select the highest level of treatment known at the time of reporting.
• Is lost time expected?
  Select if the person is expected to miss work due to the incident.

Witnesses & Immediate Response

• Were there witnesses?
  Indicate whether anyone observed the incident.
• Witness names
  Add one row per witness. Include only names and contact details needed for follow-up.
• Immediate actions taken
  Select all actions taken immediately after the incident.
• Additional response notes
  Add any other relevant response details, such as names of responders or temporary controls put in place.

Reporter & Follow-up

• Reporter name
  Enter your name if follow-up may be needed. Leave blank if submitting anonymously through another channel.
• Reporter email
  Enter an email address for follow-up questions, if desired.
• Is follow-up needed?
  Indicate whether additional investigation, corrective action, or claims support is needed.
• Consent to be contacted about this report
  Check this box if you consent to follow-up contact regarding this incident report and any related investigation.