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Incident/Injury Safety Alert Form Template

Efficiently Manage Safety Alerts and Improve Incident Reporting

When an incident occurs, timely reporting is crucial for safety and compliance. This template is designed for organizations needing a simple way to document injuries and safety alerts swiftly. With it, you can ensure accurate record-keeping, enhance communication among teams, and promote accountability, all while adhering to WCAG-aligned standards for accessibility. Explore how this safety alert form can transform your incident management process.

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Incident title
Date of incident
Time of incident
Location or site name
Exact location or area (e.g., building, room, line)
Type of event
Was there an injury?
Yes
No
Highest level of actual harm
No injury
First aid only
Medical treatment
Restricted work/transfer
Lost time
Fatality
Not applicable/Unknown
Brief description of what happened
Primary contributing factors
Please Specify:
Injured person's full name
Role or relationship
Employee
Contractor
Supervisor/Manager
Visitor
Customer
Public member
Student
Not applicable
Other
Please Specify:
Department or company
Injured person phone
Injured person email
Witness name(s)
Witness contact details
Any witnesses?
Yes
No
Injured body part(s)
Nature of injury or illness
Please Specify:
Was first aid provided on site?
Yes
No
Describe any treatment provided
Was PPE being used at the time?
Yes
No
Not required
Not applicable
Not sure
Equipment, materials, or substances involved
PPE involved
Please Specify:
Immediate actions taken
Stopped work
Provided first aid
Evacuated area
Isolated equipment
Cleaned or contained spill
Secured scene
Reported to supervisor
Removed hazard
Other
Please Specify:
Area or equipment secured/isolated?
Yes
No
Was work stopped?
Yes
No
Photos or evidence collected?
Yes
No
Did an environmental release or spill occur?
Yes
No
Were emergency services contacted?
Yes
No
Estimated actual severity
Minor
Moderate
Serious
Severe
Catastrophic
Unknown
Potential severity if circumstances differed
Negligible
Minor
Moderate
Major
Catastrophic
Unknown
How likely is a similar event to recur without changes?
0 Not at all likely
1
2
3
4
5 Extremely likely
Was your supervisor or manager notified?
Yes
No
Name of person notified
Corrective or preventive actions proposed
Responsible person for follow-up
Target completion date
Incident reported to a regulator or authority?
Yes
No
Reporter full name
Reporter role
Employee
Contractor
Supervisor/Manager
HSE/Safety
Visitor
Other
Please Specify:
Organization or department
Reporter phone
Reporter email
Reporter signature (type your full name)
Date submitted
I confirm the information provided is accurate to the best of my knowledge
Strongly disagree
Disagree
Neither
Agree
Strongly agree
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Paper art illustration representing a safety alert form template for incident and injury reporting

When to use this form

Use this form the moment an incident, injury, or near miss happens on site, on the road, or in a client space. Frontline staff, supervisors, contractors, and visitors can report a slip, fall, chemical splash, equipment failure, or a forklift near miss in minutes. Your report alerts safety leads fast, triggers temporary controls, and helps prevent repeat harm. If you also need a full investigation and root cause record, pair this alert with the Incident report form. When conditions are unsafe and work must pause, escalate alongside the Stop work authority reporting form. Clear, timely alerts help you act now and improve safety tomorrow.

Must Ask Incident/Injury Safety Alert Questions

  1. What happened, and what type of incident is it (injury, near miss, property damage, environmental)?

    This gives triage teams the context they need to set urgency and route the alert. Standard categories improve trend tracking and reduce back-and-forth.

  2. Where and when did it occur?

    Exact location and time let you notify the right area and isolate hazards fast. Timestamps also support compliance reviews and shift-based analysis.

  3. Who was involved, and how can we contact them?

    Names, roles, and contact details enable quick follow-up and support for the affected person. It also ensures witnesses can verify facts.

  4. What immediate actions were taken (first aid, stop work, equipment shutdown, containment)?

    Documenting controls shows current risk level and gaps to close. It helps the next responder know what to do next without delay.

  5. Were security or law enforcement involved, or do you suspect criminal activity?

    Flagging this early ensures proper escalation and evidence handling. For criminal events, submit or coordinate with the Crime report form.

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