INCIDENT REPORT

I. Incident Overview

Reported By: [Your Name]

Company Name: [Your Company Name]

Date of Incident: [Date]

Time of Incident: [Time]

Location: [Location]

II. Incident Details

A. Description

On [date of incident], an incident occurred involving [describe the parties involved, equipment, or environment]. The incident took place at approximately [time] in the [specific location]. The following is a detailed account of the incident:

• At [time], [describe activity and what led up to the incident].

• [Brief description of the incident].

• Immediate response and actions taken were [describe actions].

B. People Involved

Name	Role	Contact Information	Department	Comments
[Name]	[Role/Position]	[Contact Information]	[Department]	[Comments/Notes]

III. Impact Assessment

A. Injuries or Damage

The incident resulted in the following injuries and/or damage:

• [Description of injury or damage]

B. Business Impact

The incident impacted business operations in the following ways:

• [Describe operational impact, such as downtime, financial loss, etc.]

IV. Root Cause Analysis

After an initial assessment, the following were identified as potential root causes of the incident:

• [Cause 1]

• [Cause 2]

• [Additional causes, if any]

V. Corrective Actions

A. Immediate Corrective Measures

Immediately following the incident, the following corrective measures were implemented:

• [Measure 1]

• [Measure 2]

B. Long-Term Prevention Strategies

In the interest of preventing future incidents, the following long-term strategies will be enacted:

• [Strategy 1]

• [Strategy 2]

VI. Recommendations & Follow-up

It is recommended that [recommendations] to enhance safety and prevent future incidents. Follow-up evaluations will occur on [date] to assess the effectiveness of implemented changes.

VII. Signatures

Reported By:

[Your Name]

[Your Position]

[Date Signed]

Noted & Approved By:

[Supervisor/Manager Name]

[Supervisor/Manager]

[Date Signed]