Free Incident Report Template 50Free Incident Report Template 50Free Incident Report Template 50
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Health and safety incident report form
The incident
Reported by

Department

Email

Phone

Date of occurrence

Time

Ext

Exact location
Accident

Incident

Near miss

Violence

Ill health

Safety

What happened? Report any details that may have contributed to the incident (i.e., poor
lighting). Use additional paper as necessary and attach to form.

Describe the outcome: harm/health effects/damage.

Describe corrective measures taken to address immediate hazards related to incident.

Documenting Health and Safety

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Health and safety incident report form

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The affected person
Worker

other: (i.e., visitor, contractor)

Name

Address

Date of birth

Email—work:

Email—home

Employer’s name if other than
worker

Address

Phone

Witness details
Names(s) and contact information

Names(s) and contact information

First aid
First aid provided: Yes
By whom:
Details of provision:

No

N/A

Time of attendance:
Contact information:

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Documenting Health and Safety

Health and safety inc