CINQO INCIDENT REPORT FORM

Use this form to report incidents at workplace. If possible, a report should be

completed within 24 hours of the event.
Report Date: ____ 12:00 _ ☐ AM ☐ PM
PERSON INVOVLED
Name: CPR No:
Job Title: Company:
Phone: Email:
THE INCIDENT
Date of Incident: Time:
Location:
Describe the Incident:

INJURIES
Was Anyone Injured: Person involved
If Yes, Describe the injuries:

Property Damage ☐ Yes ☐ No

Environmental Impact ☐ Yes ☐ No
IMMEDIATE CORRECTIVE ACTION
Action Taken By Who Completed ☐ Yes ☐ No

WITNESSES
Was there any witness? ☐ Yes ☐ No
If Yes
Name Job Title CPR No Company Phone No

PERSON FILING REPORT

Name: Signature: Date:

PHOTOGRAPHS
 OFFICE USE ONLY
Report Received by: Date:
Signature: Phone No:
Follow-up action taken: