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Incident Statement Form Template

Effortlessly Document Incidents with Our Template

Filing an incident report can be overwhelming and time-consuming. This incident statement form template is designed for professionals in law enforcement, insurance, or any workplace needing to document occurrences efficiently. Use it to gather vital details, streamline processes, and ensure compliance with legal requirements, making your reporting accurate and straightforward. You'll save time, reduce errors, and create a consistent approach to incident documentation. Explore the live template to see how easy it can be!

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Your full name
Phone number
Email address
Your role in relation to this incident
Injured person
Witness
Reporting on behalf of someone else
Supervisor/Manager
Other
Please Specify:
Incident date
Incident time (include time zone, e.g., 3:45 PM PST)
Incident location (address, area, or description)
Incident type
Please Specify:
Was anyone injured or ill?
Yes
No
Injury severity (if applicable)
No injury
First aid only
Medical treatment
Lost time/Restricted duty
Fatality
Unknown
Not applicable
Describe what happened
Immediate actions taken
Witness names and contact details (if known)
Which services, if any, were contacted?
None
Police
Fire department
Ambulance/EMS
Poison control
Security
Unknown
Other
Please Specify:
Describe any damage and estimated cost (if known)
Was there any property, equipment, or environmental damage?
Yes
No
Suggested corrective or preventive actions
Type your full name as signature
Date signed
I confirm that the information provided is accurate to the best of my knowledge.
Yes
No
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Paper art illustration depicting an incident statement form template for FormCreatorAI

When to use this form

Use this template right after any safety, security, or behavior event at work or on your site. It helps you capture a clear first-person account while details are fresh, so supervisors, HR, and safety leads can act fast. Use it for injuries, near misses, property damage, customer incidents, or contractor issues. If an employee is hurt, pair it with the Employee accident report form. For suspected shoplifting or missing assets, add the Theft report form. When multiple statements come in for the same event, keep them organized with the Incident report tracking form. The result: consistent facts, timelines, and next steps that support investigations, insurance, and corrective action.

Must Ask Incident Statement Questions

  1. What happened, in your own words, from start to finish?

    Your step-by-step account sets the timeline and reduces assumptions. Clear sequencing helps reviewers confirm facts and spot gaps.

  2. When did it occur, and where exactly did it take place?

    Precise date, time, and location let teams pull video, logs, and staffing records. It also helps match your statement to other reports or policies.

  3. Who was involved or witnessed the event, and how can we contact them?

    Names, roles, and contacts speed follow-up and corroboration. For lost property, route details alongside the Housekeeping hotel lost and found form.

  4. What conditions or hazards were present at the time?

    Note equipment status, weather, lighting, PPE, and workload to inform root cause analysis. These details guide prevention steps and training updates.

  5. What did you do immediately after the incident, and who did you tell?

    Document first aid, shutdowns, isolation, and notifications to show proper response. This supports compliance, workers compensation, and insurance claims.

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