Incident Report Template (Word)

What it's for

This incident report template is a two-page Word form for writing down an event on a job: when and where it happened, who was involved, what was seen, what was done at once and what changes afterward.

Use it for any event your firm wants on paper: an injury, a near miss, damage to equipment or to someone else's property. A TYPE row says which. It is a record of what happened, not a claim form, and it goes to no one on its own. If someone is hurt, our guide to workers' comp for contractors explains that insurance.

The form does not decide whether an event has to be reported to anyone, or by when. Three forms sit beside it: a job hazard analysis, a site specific safety plan and a toolbox talk sign-in sheet.

What's inside

Two Letter-size pages, with our logo, a credit link and the page number in each footer. The pale yellow boxes are yours to fill in, and nothing calculates. The letterhead has YOUR LOGO, Your Company Name, address and contact lines, the title INCIDENT REPORT, and Report no. and Date.

Page 1

• INCIDENT: DATE OF INCIDENT, TIME, LOCATION ON SITE, PROJECT, TYPE (Injury, Near miss, Property damage, Other), REPORTED BY and PHONE.
• PEOPLE INVOLVED: four rows under NAME, COMPANY OR TRADE, ROLE and PHONE.
• WHAT HAPPENED: five numbered lines.
• INJURY OR DAMAGE: INJURY OR DAMAGE DESCRIBED, CARE GIVEN (None, First aid on site, Care off site), GIVEN BY and EQUIPMENT OR PROPERTY.

Page 2

• WITNESSES: three rows under NAME, COMPANY OR TRADE and PHONE.
• IMMEDIATE ACTIONS TAKEN: three numbered lines.
• CONTRIBUTING FACTORS: three numbered lines.
• CORRECTIVE ACTIONS: four rows under NO., ACTION, RESPONSIBLE, DUE and DONE, numbered 1. to 4.
• SIGN-OFF: a sentence, then REPORTED BY and REVIEWED BY, each with SIGNATURE, PRINTED NAME AND TITLE and DATE.

The sentence reads: "Signed below, the person reporting and the reviewer confirm this report is complete as far as they know. A completed report is a record, not a finding of fault or a compliance determination."

How to fill it in

1. Delete the words YOUR LOGO and insert your logo. Replace Your Company Name, fill in the address and contact lines, then type over the underscores after Report no. and Date. The letterhead Date is separate from DATE OF INCIDENT.
2. Under INCIDENT, name the place so someone arriving cold could find it: "east stair, second floor", not "the building". Mark TYPE by typing an X over a ☐. The boxes are typed characters, not checkboxes you click.
3. List each person under PEOPLE INVOLVED.
4. Under WHAT HAPPENED, write one thing per numbered line, in the order it occurred, with times where you have them.
5. Describe any injury or damage, mark CARE GIVEN and name who gave it. Put the machine, tool or part of the building under EQUIPMENT OR PROPERTY. For a near miss with no injury or damage, write "none" on the description line.
6. On page 2, list the WITNESSES and what was done right away.
7. Use CONTRIBUTING FACTORS for the conditions and decisions that led up to it.
8. For each item under CORRECTIVE ACTIONS, write the action, one name under RESPONSIBLE and a DUE date. Fill in DONE when it is finished.
9. The reporter and the reviewer sign and date under SIGN-OFF.

Writing a report people can use later

Write it the day it happens, while the details are fresh. Keep WHAT HAPPENED to what people saw and did, and put your view of why in CONTRIBUTING FACTORS, so the two do not blur. Use names, places and times in place of "the worker" or "earlier".

The last table is where a report pays off. An action with one owner and a due date is easy to follow up; "be more careful" is not. Fill in DONE as each one closes, and keep the finished copy with the job's records.

Frequently asked questions