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Run: Workplace Incident Report

A Workplace Incident Report template for documenting injuries, illnesses, and near-misses with the facts needed for follow-up, OSHA logging, and workers' com...

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Report Overview

Date of incident (required)

Select the date the incident occurred.

Time of incident (required)

Enter the approximate time the incident occurred.

Date reported (required)

Select the date this report is being submitted.

Type of incident (required)

Choose the option that best describes what happened.

Reporter role (required)

Select your relationship to the incident.

Brief incident summary (required)

Describe what happened in 1-3 sentences. Focus on observable facts, not opinions.

Affected Person

Affected person type (required)

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 (required)

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 (required)

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 (required)

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 (required)

Describe the injury or illness symptoms using observable facts.

Medical treatment provided (required)

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? (required)

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 (required)

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? (required)

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.

Yes No N/A

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Email (required)

Your name (optional)

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