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Safety Incident Report Form

Complete as soon as practicable after any workplace incident: injury, near miss, property damage or environmental event

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PAGE 1 OF 2

Incident Details
Injured / Affected Person Details
Incident Type
Injury / illness Near miss Property damage Environmental Dangerous occurrence Other: _______________
Description of Incident: What Happened
Injury / Damage Description & Body Area
Immediate Actions Taken
PAGE 1 OF 2  ·  Safety Incident Report Form  ·  MapTrack template
Incident date
Reported by
Safety Incident Report - Page 2 of 2
Incident date
Reported by
Witness Details
Witness Statement(s)
Contributing Factors
Root Cause Analysis

Corrective / Preventive Actions

# Action required Responsible person Due date Status
1
2
3
4

Declaration

I declare that I have completed this incident report to the best of my knowledge. All details are accurate and any injuries, damage or hazards have been reported to the relevant supervisor and safety personnel. Corrective actions have been identified and assigned to responsible persons with due dates.

Investigator / Reporter Sign-off
Signature
Print name
Date & time
Supervisor / Safety Officer Acknowledgement
Signature
Print name
Date

PAGE 2 OF 2  ·  Safety Incident Report Form  ·  MapTrack template  ·  Rev 2026-02
Free template from MapTrack. For digital incident reporting on mobile with automatic alerts and corrective action tracking, see maptrack.com