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Special Incident Report Form Template

Effortlessly document and resolve workplace incidents

Experiencing an incident at work can be stressful, but collecting the right details shouldn't be. This Special Incident Report Form Template helps you efficiently document incidents, ensuring your team can respond swiftly and effectively. You'll benefit from clear structure, easy sharing options, and compliance with workplace safety regulations, all while maintaining a record that enhances accountability. Whether you need to report minor accidents or serious hazards, this template is designed to streamline your process. Try the live template to see how it simplifies reporting.

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Your full name
Department or team
Email address
Phone number
Your relationship to the incident
Witness
Involved party
Supervisor/manager
Safety/HSE staff
HR
Other
Please Specify:
Date of incident
Time of incident (24-hour, HH:MM)
Exact location of incident
Incident type
Please Specify:
Severity assessment
No injury or damage
Minor
Moderate
Major
Critical
Unknown
Brief description of what happened
Contributing factors (select all that apply)
People involved (select all that apply)
Employee
Contractor
Visitor
Customer
Member of public
Not applicable/none
Unknown
Names and contact details of involved persons (if any)
Did an injury or illness occur?
Yes
No
Nature of injury or illness
Please Specify:
Body part affected
Treatment provided
None
First aid on site
Clinic or urgent care
Emergency room
Hospital admission
Unknown
Not applicable
Describe the damage and estimated cost (if known)
Was there any property or equipment damage?
Yes
No
Witness names and contact details
Were there any witnesses?
Yes
No
Immediate actions taken (select all that apply)
Please Specify:
Notifications made (select all that apply)
Please Specify:
Proposed corrective or preventive actions
Person responsible for follow-up
Target completion date
Signature (type your full name)
Date signed
I certify the information provided is accurate to the best of my knowledge
True
False
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Paper art illustration depicting a special incident report form template for FormCreatorAI article

When to use this form

Use this form when a serious, unusual event affects safety, security, or operations and needs a formal record. It suits facility managers, security teams, supervisors, and contractors who must capture facts fast and alert the right people. Typical cases include an on-site injury, a physical fight, major property damage, or an evacuation. If the issue is strictly security-related, consider the Security incident report form. For behavior that seems threatening but not yet criminal, use the Suspicious activity report form. When a person cannot be located during a shift or event, the Missing person form helps you mobilize support. The result is a clear, time-stamped report that supports triage, insurance, compliance, and prevention.

Must Ask Special Incident Report Questions

  1. What happened, where, and when?

    Time and location anchor the facts and make your account easy to verify. Clear details help teams match reports with CCTV, access logs, and shift records.

  2. Who was involved and how can we contact them?

    Names, roles, and contact details enable fast follow-up with victims, witnesses, and responders. This supports interviews, claims, and any regulatory reporting.

  3. What immediate actions did you take?

    Documenting steps like first aid, evacuation, or shut-down shows due diligence and speeds review. If no harm occurred but risk was high, also log it with the Near-miss incident report form.

  4. What evidence or documentation is available?

    List photos, video, badges, sensor alerts, or system logs to preserve proof and reduce disputes. If systems or apps were affected, route technical details with the Software incident report form.

  5. What was the impact and current status?

    Describe injuries, service downtime, property loss, and whether the area is secure. This helps leaders set priority, assign resources, and decide on notifications.

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