Free Incident Report Template
Incident Report
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Prepared By: [Your Name] |
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Company: [Your Company Name] |
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Date: May 20, 2054 |
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Time: 10:15 AM |
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Location: Main Office, Building A, 3rd Floor, Conference Room 301 |
1. Incident Details:
Description of Incident: A slip and fall accident occurred in Conference Room 301 when an employee, John Doe, slipped on a wet floor surface.
Type of Incident: Accident/Injury
Witnesses: Jane Smith (HR Manager), Sarah Johnson (Office Assistant)
2. Injuries or Damages:
Injuries Sustained: John Doe sustained a sprained ankle and minor bruising.
Property Damage: No property damage was reported.
3. Actions Taken:
Immediate Response: First aid was administered to John Doe by the office nurse. The area was cordoned off to prevent further accidents.
Notifications Made: HR and management were immediately notified of the incident. The building maintenance team was called to address the wet floor.
4. Root Cause Analysis:
Investigation Findings: Upon investigation, it was discovered that the wet floor was caused by a spill from a coffee cup that was accidentally knocked over.
Root Cause(s): Failure to promptly clean up the spill and insufficient warning signage in the area.
5. Preventive Measures:
Recommendations: Implement regular inspections of common areas for potential hazards and ensure prompt cleanup of spills. Additionally, increase awareness among employees regarding the importance of reporting and addressing hazards promptly.
6. Signatures:
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Report Prepared By: [Your Name]
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Date: [Date Signed]
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Reviewed By: [Manager's Name]
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Date: [Date Signed]
Additional Notes:
The incident report was reviewed and approved by [Manager's Name] for accuracy and completeness.
Attachments:
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Photographs of the wet floor area.
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Witness statements from Jane Smith and Sarah Johnson.
Confidentiality Notice:
This incident report contains confidential information and is intended solely for the use of authorized personnel. Unauthorized disclosure, distribution, or copying of this report is strictly prohibited.
