Template

Incident and Injury Report Form

by Joar Baricante, from the Community

10+

This Incident and Injury Report Form helps teams document workplace incidents and injuries in detail. The template covers personal and incident details, witness information, supervisor or manager notification, injury and illness specifics, and time lost. An investigation checklist guides root cause analysis across factors like training, environment, equipment condition, housekeeping, surfaces, footwear, workload, slips and trips, vehicles, insects or animals, and manual handling. It records PPE use, service dates, and SWMS adherence. The WHS manager section outlines risk control options and corrective actions, assigns responsibilities and due dates, and captures feedback to the reporting worker.

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

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
SafetyCulture Incident and Injury Report Form
Use this customizable Incident and Injury Report Form to record workplace accidents, injuries, and near misses. Capture personal and incident details, witness information, injury specifics, and time lost. Includes an investigation checklist covering contributing factors, equipment condition, environment, PPE, surface types, and manual handling. WHS managers can add findings and assign corrective actions using the hierarchy of controls, with owners and due dates. Ideal for workshops and industrial sites, and adaptable across industries to improve safety and compliance.
by Darryl Bancale, from the Community
Downloads: 20+
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Template
Incident/Injury Report Form
Use this Incident/Injury Report Form to document workplace events quickly and accurately. Capture personal and incident details, supervisor and WHS manager notifications, injury type and affected body part, treatment and time lost, and a full investigation checklist. Record contributing factors, equipment and PPE used, surface and environment conditions, manual handling actions, and preventive measures. Close the loop with corrective actions using the hierarchy of controls (elimination, substitution, engineering, administration, PPE), assign owners and due dates, and track recommendations to completion. Ideal for WHS compliance across industrial and field environments.
by Christina Edlaine De Jesus, from the Community
Downloads: 0
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Template
Injury Investigation Form Template
Use this injury investigation form to document a first report of injury or illness. Capture employee and incident details including date, time, location, injury type, and body part affected; eyewitness information; environmental conditions; underlying factors such as PPE use, equipment issues, and training gaps; and recommended corrective actions. Attach photos or media, assign actions, and record investigator and supervisor sign-off. Suitable for construction and other industries to support incident reporting and root cause analysis.
by Jonathan Nixon, from the Community
Downloads: 0
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Template
Incident and Injury Report Form Template
This Incident and Injury Report Form helps teams record and investigate workplace accidents quickly and consistently. The template guides users to capture essential details such as incident time and location, parties involved, injury specifics, contributing factors, equipment condition, PPE use, and manual handling elements. It includes prompts for WHS Manager and Supervisor notifications, investigator observations, and corrective actions across elimination, substitution, administration, and PPE controls. Ideal for workshops and general operations, it supports thorough WHS investigations, consistent reporting, and faster follow-up. Customizable within SafetyCulture.
by Roger Mercado, from the Community
Downloads: 30+
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Incident and Injury Report Form

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