Incident Report Checklist
This procedure is a comprehensive incident reporting that can help your business understand what is going wrong or could go wrong regarding workplace safety. With these insights, an organisation can fix a health and safety issue before it becomes a bigger problem that can cause serious harm or damage to employees or property
DSV Solutions
06/23/2022
Incident Report Checklist
This procedure is a comprehensive incident reporting that can help your business understand what is going wrong or could go wrong regarding workplace safety. With these insights, an organisation can fix a health and safety issue before it becomes a bigger problem that can cause serious harm or damage to employees or property
This form must be completed within 24 hours of the Supervisor learning of the incident
Last name:
First Name:
Job Title:
Department:
Employee involved with the incident :
Date & Time of Incident:
Date Reported:
Description of Incident:
Witnesses to the incident: (names and phone numbers)
Describe if there is personal injury
THIS SECTION TO BE COMPLETED BY THE SUPERVISOR
Contributing Factors: What conditions contributed to the incident?
Explanation of contributing factors:
Details of property damage (if any):
To your knowledge, has the employee had a previous similar injury or has this similar hazard been reported before?
Explanation of corrective measures:
Attach pictures of incident if any
Add or drag pictures
Signature of Supervisor:
Click here to sign
Date:
Source: DSV Solutions (Community Member)