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Incident Report Form

Workplace incident notification and initial response record

Company logo

PAGE 1 OF 2

Incident Details
Incident Type
Personal injury Near miss Property damage Environmental Vehicle / plant Other: _______________
Severity:
Minor Moderate Serious Critical
Description of Incident

Persons Involved

# Name Role / Position Employer Injury / Damage Description
1
2
3

Witness Details

# Name Contact Statement Summary
1
2
PAGE 1 OF 2  ·  Incident Report Form  ·  MapTrack template
Reported by
Date
Incident Report - Page 2 of 2
Reported by
Date
Immediate Actions Taken
Root Cause / Contributing Factors

Corrective Actions

# Action Required Responsible Person Due Date Completed
(tick)
1
2
3
4
Notifications

Tick all parties that have been notified as a result of this incident.

Regulator (SafeWork / WorkSafe) Insurer Client / principal contractor Emergency services Other: _______________

Declaration

I confirm that the information recorded in this incident report is accurate and complete to the best of my knowledge. I understand that this report may be used for investigation, regulatory notification, insurance and corrective action purposes.

Reported By
Signature
Print name
Date
Supervisor / Manager
Signature
Print name
Date
WHS Officer / Coordinator
Signature
Print name
Date

PAGE 2 OF 2  ·  Incident Report Form  ·  MapTrack template  ·  Rev 2026-04
Free template from MapTrack. For digital incident reporting with automatic notifications and corrective action tracking, see maptrack.com