Incident Reporting Form Template

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LOGO	HSE
INCIDENT/nearmiss fORM

Report Status:	Preliminary	Type:	Incident		Incident No:
General Information				Evaluation of Risk
Incident Date:				Loss Severity Potential:
Incident Time:				Company Name
Location of Incident:				Probable Recurrence Rate:
Section:
Employee Name/ID No
Occupation:
Service In The Job
Supervisor/Incharge:
Shift:
Witness:

Events Leading up to and Description of Incident (Include Description and Losses)

(What, When, Where, Why, Who, How)

Cause Analysis – Direct and Underlying
The Unsafe Practices, Condition Contributory Factors most directly causing the event.
Unsafe Practice/s:
Unsafe Condition/s:
Contributory Factor/s:
Direct Cause/s:
Root Cause/s:

Preventive And Corrective Actions
Corrective Actions:
Preventive Action:

Injury Information
Type of Injury:		Body Part Injured:
Cause of Injury:
Agency of accident (Energy Source):
First Day of Lay-Off
Date of Return To Work:		Number of Working Days Lost: