Free Incident Report Template 23
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Accident/Incident/Early Reporting Form
Work Area / Department
First Aider (write name clearly)

Time of Incident hh:mm pm / am

Incident Date

dd/mm/yyyy

Injured Employee Name : Enter here

Time started Shift hh:mm pm / am

Date of Report

dd/mm/yyyy

Date of birth dd/mm/yyyy:

Witness

TREATMENT (Tick appropriate box) Nil 

First Aid 

Doctor 

Hospital 

STATUS (tick appropriate box) Permanent  Fixed Term  Contractor  Other  (please state)
Discomfort/Injury Details – Body Part

Discomfort/Injury Type (tick)

8. Description of Accident / Incident: (please describe your interpretation of events)
Enter here

9. Information for Discomfort for Early Reporting:
- When did you first notice discomfort / pain?
- Is it getting worse, better or staying the same?
- Have you had this discomfort/pain before?
- What are you doing to help relieve the discomfort/pain?
- Is there anything else you feel we should know? (note on reverse)

Root Cause(s) of
Incident

Severit