Template

Adverse Event Report..

by Paul McConnell, from the Community

40+

A comprehensive incident reporting and investigation system designed to document workplace incidents, accidents, injuries, and near-misses. The form covers essential details including incident type, severity assessment, weather conditions, involved parties, injury documentation, and evidence collection. It features a structured approach to root cause analysis, corrective actions, and multiple management review levels. The system includes detailed sections for recording witness statements, medical attention provided, equipment involved, and damage assessment. A thorough sign-off process ensures proper review by tier one and tier two management, with additional protocols for serious incidents requiring Senior Management Team or Managing Director involvement. The form emphasizes factual documentation and includes provisions for photos, evidence logging, and follow-up actions to prevent future occurrences.

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With SafetyCulture you can

Digitize any process, procedure or policy

Eliminate mistakes made by paper-based processes

Create and share professional reports instantly

Confirm accountability and compliance with a digital log

About author

Community

This community page makes available free workplace checklists and templates created by other users within the SafetyCulture community. SafetyCulture has re-published this content and where possible, has credited the original author. SafetyCulture has not verified the accuracy, reliability or suitability of any community content. You agree that your use of any of this content is in accordance with SafetyCulture’s Terms and Conditions.

Template
INCIDENT/NEAR MISS INVESTIGATION REPORT and FIRST REPORT OF INJURY
This document represents a detailed workplace incident investigation form designed to thoroughly document and analyze workplace accidents, injuries, and near-misses. The form includes essential sections for incident identification, employee information, injury details, investigation analysis, equipment involvement, training verification, and corrective actions. It also covers management review processes, insurance reporting requirements, and follow-up procedures. The form ensures proper documentation of workplace incidents while facilitating systematic investigation and implementation of preventive measures. Key components include incident location details, witness statements, PPE verification, and management sign-offs, making it a crucial tool for maintaining workplace safety standards and regulatory compliance.
by Jason Richey, from the Community
Downloads: 50+
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Template
Adverse Event Report Template
This adverse event report template helps teams document workplace incidents comprehensively. Capture incident details, weather conditions, and parties involved, including witness statements and signatures. Record injury types, affected body parts, and medical attention provided. Log evidence, equipment, vehicles, and damages. Perform root cause analysis, assess likelihood of recurrence, and define corrective actions. Includes tiered management sign-offs and meeting records to review controls, ensure accountability, and support regulatory compliance, including RIDDOR-aligned severity levels.
by Paul McConnell, from the Community
Downloads: 0
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Template
TECSIDE Accident / Incident / Hazard Report and Investigation Form
A comprehensive workplace incident reporting document designed to capture detailed information about workplace accidents, injuries, and hazards. The form includes sections for personal information, incident details, injury classification, witness statements, and root cause analysis. It covers various types of incidents from minor injuries to lost time injuries, property damage, and environmental incidents. The document also includes sections for corrective actions, contributing factors analysis, and recommendations for future prevention. This structured approach ensures thorough documentation of workplace incidents and helps organizations maintain safety standards while implementing preventive measures. The form requires signatures from both the host employer and TECSIDE representative, ensuring proper oversight and accountability in incident reporting and resolution.
by Anthony O'Donnell, from the Community
Downloads: 60+
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Template
Full Incident Investigation and Report
This incident investigation template helps teams collect evidence, document incident details, and perform root-cause analysis for hazards, near-misses, accidents, injuries, and property damage. It includes sections for timelines, weather conditions, evidence and attachments, vehicle and equipment logs, damage records, people involved and statements, injury classifications and affected body parts, corrective actions, and sign-off. Use it to create a thorough, compliant investigation report that goes beyond an initial incident report and supports prevention and follow-up.
by Craig Lee, from the Community
Downloads: 10+
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Adverse Event Report..

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