Incident report: [Short description]

One report per incident, written the same day. Replace the blue placeholders and delete the grey notes as you go.

Report number	[IR-YYYY-NNN]
Type	[Injury or illness / near miss / property damage / security / IT or service]
Date of incident	[Date]
Time	[Time, approximate if needed]
Location	[Exact place: site, room, aisle or system]
Reported by	[Name, role]
Date of report	[Date]

People involved

Everyone who was hurt, involved or saw what happened.

Name	Role	Part in the incident	Contact
[Name]	[Job title]	[Injured / involved / witness]	[Phone or email]
[Name]	[Job title]	[Injured / involved / witness]	[Phone or email]
[Name]	[Job title]	[Injured / involved / witness]	[Phone or email]

What happened

Facts in time order: what the person was doing, what happened, what happened next, when the area was made safe. Quote people exactly. Say who saw or told you each fact.

[Describe the events in time order]

See an example description

Marcus's account, given to Dana at 10:50 a.m.: at about 10:40 a.m. he climbed the two-step ladder in aisle B to reach a carton on the top shelf. As he stepped onto the second step, the ladder's left foot slid on the tile floor. He stepped down quickly onto his right foot and his ankle turned. He did not fall.

Jo's account: she was shelving in aisle C, heard the ladder scrape and reached him within a few seconds; she didn't see the slip itself. Marcus told her, “My ankle went over.”

Found by Dana when she arrived: the carton was still on the shelf, the floor was dry, and the ladder's left rubber foot was worn through to the metal.

Time order, one exact quote, and a source for every fact. No blame and no diagnosis.

Facts, not blame. Keep reasons for the root-cause section, where they can be checked. Don't write a diagnosis unless a clinician gave one.

Injuries or damage

Injury or illness	[Body part and side, what could be seen]
First aid or treatment	[What was given, by whom, at what time]
Left work or saw a clinician	[Yes or no, and when]
Property or equipment damaged	[Asset, ID number, what is damaged]
Estimated cost	[Amount, if known]
Photos	[Where the photos are saved]

Witnesses

Take each statement separately, in the witness's own words.

Witness	What they saw or heard	Statement taken by	When
[Name]	[Their account, briefly]	[Name]	[Date and time]
[Name]	[Their account, briefly]	[Name]	[Date and time]

Immediate actions

For the people involved: [first aid, transport, who stayed with them]
To make the area safe: [what was closed, removed, tagged or switched off]
Who was told: [names and times]

Root cause

Ask why until the answer is something the organization can change: a missing check, a worn part, a gap in a procedure. Say whose analysis it is.

Question	Answer
Why did it happen?	[Answer]
Why was that possible?	[Answer]
Why wasn't it caught earlier?	[Answer]
Root cause	[Something the organization controls]

See an example chain of whys

Why did the ladder slip? Its foot was worn through to the metal.

Why wasn't the wear noticed? Ladders weren't on any inspection list.

Why not? The opening checklist was written before the stockroom had ladders.

Root cause: no inspection routine for ladders and step stools.

Corrective and preventive actions

Action	Owner	Due	Done
[What will change]	[Name]	[Date]	[Date or open]
[What will change]	[Name]	[Date]	[Date or open]
[What will change]	[Name]	[Date]	[Date or open]

Details for this type of incident

Keep the rows for your type of incident and delete the rest.

Near miss	[What could have happened, and what stopped it]
Security	[What was taken, opened or seen; how entry happened; police report number; camera time range]
Vehicle	[Other party's name, insurer and registration; whether your insurer was told]
IT or service	[Start and end time; how it was detected; who or what was affected; link to the postmortem]

Official forms. This is an internal report. In the US, a recordable work-related injury or illness may also need an entry on the OSHA 300 Log and an OSHA Form 301 or equivalent form within seven calendar days. Check with HR or your insurer which forms apply to you.

Follow-up and sign-off

Follow-up	[Check-ins with the person involved, review meeting and date]
Reviewed by	[Name, role, date]
Read by the person involved	[Name, date]
Closed on	[Date, or which actions are still open]

Before you file it

The description is in time order and could be checked by someone who wasn't there
Quotes are exact, and what others said is labeled as theirs
No blame, guesses or diagnoses outside the root-cause section
Every witness statement says who took it and when
Every corrective action has an owner and a due date
Any official forms that apply are filed or assigned to someone