Incident Report Form Checklist - SafetyCulture

24/08/2021 Incident Report Form Checklist - SafetyCulture
GO DIGITAL TODAY
Convert your paper

checklists into digital forms
Scan this QR code to use this
paper checklist on your
smartphone or tablet. Visit

www.iauditor.com
What Type of Incident Occurred? Please read through the following options and select the
type you think best describes the incident.
What is the Difference Between an Accident and an Incident?
The term incident is often interchanged with an accident. Similarly, both events are triggered
by unexpected things, however, these two terms are totally different from each other. An
incident can be any event that might or might not result in critical or serious damage or
injury, while an accident always results in minor or major injuries or illnesses and property
damages.
Sentinel events – these are unexpected occurrences that resulted in serious physical or
psychological injury or death (e.g. slips, trips and falls, natural disasters, vehicle accidents,
disease outbreak, etc.).
Yes No N/A
Near misses – these are situations where the people involved had no injuries but could have
been potentially harmed by the risks detected.
Yes No N/A
https://public-library.safetyculture.io/products/incident-report-form-n39oj?referrer=https%3A%2F%2Fsafetyculture.com%2Ffr%2Flistes-de-verific… 1/21
Adverse events – related to medicine, vaccines, and medical devices. These events occur
when an act of commission or omission harmed a patient rather than from the existing
disease or condition.
Yes No N/A
No harm events – these are incidents that need to be communicated across an organization
to raise awareness of any harm that may happen.
Yes No N/A
Guidelines for Completing Incident Report's
Accurate
-All data must be clear and specific. Most inaccuracies are due to typos and simple
grammar and spelling errors (e.g. incorrect details of names of people involved, date and
time of the incident, contact numbers, etc.). Provide more specific details of what you are
referring to and avoid any vague statements that may cause confusion. Lastly, always
proofread your report before submission to see errors that you might have overlooked.
Factual
-An incident report should be objective and supported by facts. Avoid including emotional,
opinionated, and biased statements in the incident report. It should provide both sides of
the story and should not favor one side. However, if there’s a need to include statements
from witnesses or patients, make sure to quote them.
Complete
-Ensure that all essential questions (what, where, when, why, and how) are covered in the
incident report. Record not only the people who were injured and what caused the accident
to happen, but also include details such as people who witnessed and reported the incident
or those who will conduct an investigation. Anticipate what other significant details will be
needed for any future study and investigation.
Graphic
-Photos, diagrams, and illustrations should be included as supporting evidence. Take many
photos of the injury, damage, and surrounding environment. This supplements the facts
stated and provides more clarity to be easily understood by the recipient.
Valid
-Upon completion, those who are involved in the incident (e.g. victim, witnesses, manager,
reporter, etc.) should sign off to testify and validate all the information that was mentioned
in the incident report. This confirms that the incident report is truthful and unquestionable.
Person Involved in The Incident
Did this incident result in any injuries?
Yes No N/A
Name
Enter text
DOB 
Sex
Male Female
Contact Number/ Email
Enter text
2. Job Details (if applicable)
Job Title
Enter text
How long in this occupation
Enter text
Start time 
Hours worked
Shift arrangement
Training/ Qualifications
Incident Details
General Staff Incident
Yes No N/A
Yes No N/A
Occurred 
Reported 
Location of incident 
How did the Accident/Near Miss Happen?
Where did the Accident/Near Miss Happen?
Description of any of injury, illness or property damage
Enter text
Were other people involved in this incident?
Yes No N/A
Did anyone witness this incident?
Yes No N/A
Who witnessed this incident ?
Was the person trained for the task they were doing?
Yes No N/A
Was a significant hazard involved?
Yes No N/A
How serious could the incident have been?
Critical Moderate Not Serious
Take/ upload photo evidence of incident, environment, person(s)

involved 
Date reported to regulatory authority (leave blank if not required) 
Date Incident Report Sent to HR 
Incident Report Saved to S Drive
Yes No N/A
4. Staff Witness Statements (if applicable)
Witness
Name
Enter text
Job Title
Enter text
How long in this occupation
Enter text
Were you working when you witnessed this incident?
Yes No N/A
Contact
Enter text
Statement
What did you see?
Enter text
Witness signature 
https://public-library.safetyculture.io/products/incident-report-form-n39oj?referrer=https%3A%2F%2Fsafetyculture.com%2Ffr%2Flistes-de-verifi… 10/21
Name
Enter text
Reason for Visiting Urbn Leaf
Enter text
What were you doing when you witnessed this incident?
Yes No N/A
Contact Information:
Name:
Phone Number:
Email Address:
Statement
What did you see?
Enter text
By signing this witness statement, you acknowledge that Urbn Leaf may contact you via the
information you provided and/or provide your contact information to other required parties.
Witness signature 
Date & Time 
Was this an incident involving violence or the potential for violence?
Yes No N/A
Type of incident (check all that apply)
Yes No N/A
Grabbed Pushed Slapped
Yes No N/A
Kicked Scratched Hit with fist
Yes No N/A
Hit with object Bitten Stabbed (or attempted)
Yes No N/A
Shot (or attempted) Sexually assaulted Assaulted with weapon
Yes No N/A
Threatened with weapon Verbally harassed Verbally threatened
Yes No N/A
Bomb threat Animal attack Robbery Arson
Yes No N/A
Vandalism (employer’s property) Vandalism (own property) Other
Yes No N/A
What type of weapon was used? How was the weapon obtained?
Yes No N/A
Were security personnel on duty at the time of the assault? If yes, was security notified?
Yes No N/A
Did security respond? When?
Who threatened or assaulted you?
Yes No N/A
Client/customer Patient
Yes No N/A
Family/friend of client or patient
Yes No N/A
Co-worker Supervisor/manager
Stranger Animal
Yes No N/A
Friend Family Member Spouse or partner Former spouse or partner
Other - Please Explain
Robber/burglar
Yes No N/A
Were any threats made before the incident occurred? If yes, did you ever report to your
supervisor or manager that you were threatened, harassed or suspicious that the attacker
may become violent?
Yes No N/A
Has this type of incident occurred before at the workplace?
Yes No N/A
What do you think were the main factors that contributed to the incident?
What could have prevented or at least minimized the damage caused by this incident?
Additional observations and comments (If Applicable)
Enter text
Name and signature of reporting person 
Post Incident Supervisor Follow Up
Is there an Action Plan to prevent the same/ similar incident from reoccuring?
Yes No N/A
Summary of Action Plan:
If no, when will your Action Plan be completed?
Has this Plan been implemented ?
Yes No N/A
If yes, when? If no, when is the expected implementation date?
What Locations will utilize this plan?
Bay Park La Mesa San Ysidro Grover Beach Seaside Vista
Follow Up Questions For Individual Who Reported the Incident
Has HR followed up with you regarding this incident?
Yes No N/A
Has Management followed up with you regarding this incident?
Yes No N/A
Was this incident handled in an efficient and professional manner?
Yes No N/A
Do you have any additional questions regarding this incident?
Yes No N/A
Did you miss work as a result of the incident?
Yes No N/A
Did you apply for workers’ compensation?
Yes No N/A
Was the incident reported to a supervisor or manager?
Yes No N/A
Was a police report filed?
Yes No N/A
Was immediate counseling provided to affected workers and witnesses who desired it?
Yes No N/A
Was critical incident debriefing provided to all affected staff who desired it?
Yes No N/A
Was post-trauma (follow-up) counseling provided to all affected staff who desired it?
Yes No N/A
Was all counseling provided by a professional counselor?
Yes No N/A
Was the counseling effective?
Yes No N/A
Was the victim advised about legal rights?
Yes No N/A
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended
to
take the place of, among other things,
workplace, health and safety advice; medical advice, diagnosis, or
treatment;
or other applicable laws. You should also seek your own professional advice to
determine if the use of such
checklist is
permissible in your workplace or jurisdiction.

Incident Report Form Checklist - SafetyCulture

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Incident Report Form Checklist - SafetyCulture

Uploaded by

Copyright:

Available Formats

24/08/2021 Incident Report Form Checklist - SafetyCulture

Convert your paper

What is the Difference Between an Accident and an Incident?

Guidelines for Completing Incident Report's

Person Involved in The Incident

Did this incident result in any injuries?

Contact Number/ Email

2. Job Details (if applicable)

How long in this occupation

General Staff Incident

How did the Accident/Near Miss Happen?

Where did the Accident/Near Miss Happen?

Description of any of injury, illness or property damage

Were other people involved in this incident?

Did anyone witness this incident?

Who witnessed this incident ?

Was a significant hazard involved?

How serious could the incident have been?

Critical Moderate Not Serious

Take/ upload photo evidence of incident, environment, person(s)

Date reported to regulatory authority (leave blank if not required) 

Date Incident Report Sent to HR 

Incident Report Saved to S Drive

4. Staff Witness Statements (if applicable)

How long in this occupation

Were you working when you witnessed this incident?

Reason for Visiting Urbn Leaf

What were you doing when you witnessed this incident?

Date & Time 

Was this an incident involving violence or the potential for violence?

Type of incident (check all that apply)

Grabbed Pushed Slapped

Kicked Scratched Hit with fist

Hit with object Bitten Stabbed (or attempted)

Shot (or attempted) Sexually assaulted Assaulted with weapon

Threatened with weapon Verbally harassed Verbally threatened

Bomb threat Animal attack Robbery Arson

Vandalism (employer’s property) Vandalism (own property) Other

Did security respond? When?

Who threatened or assaulted you?

Family/friend of client or patient

Friend Family Member Spouse or partner Former spouse or partner

Other - Please Explain

Has this type of incident occurred before at the workplace?

Additional observations and comments (If Applicable)

Name and signature of reporting person 

Post Incident Supervisor Follow Up

Summary of Action Plan:

If no, when will your Action Plan be completed?

Has this Plan been implemented ?

If yes, when? If no, when is the expected implementation date?

What Locations will utilize this plan?

Bay Park La Mesa San Ysidro Grover Beach Seaside Vista

Follow Up Questions For Individual Who Reported the Incident

Has HR followed up with you regarding this incident?

Has Management followed up with you regarding this incident?

Was this incident handled in an efficient and professional manner?

Do you have any additional questions regarding this incident?

Did you miss work as a result of the incident?

Did you apply for workers’ compensation?

Was the incident reported to a supervisor or manager?

Was a police report filed?

Was all counseling provided by a professional counselor?

Was the counseling effective?