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Staff Incident Report Form Template

Effectively Document Employee Incidents with This Template

When an incident occurs, having a clear report can make all the difference. This staff incident report form template helps you accurately document workplace incidents, ensuring you meet compliance requirements and protect your employees. With this template, you can track injuries, manage claims, document hazardous conditions, improve safety protocols, and train staff effectively. Easily customize it for your organization and start enhancing your reporting process now.

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Your full name
Job title or role
Department or team
Phone number
Work email
Are you the person directly involved in this incident?
Yes
No
Incident date
Incident time (e.g., 14:30)
Location or site
Exact location or area (e.g., room, line, equipment ID)
Type of incident
Please Specify:
Severity assessment
Minor - no treatment required
Minor - first aid only
Moderate - medical treatment
Major - hospitalization
Critical or fatal
Unknown
Was medical treatment required beyond first aid?
Yes
No
Was work stopped due to this incident?
Yes
No
Was the area made safe immediately?
Yes
No
Number of people directly involved
1
2
3
4 or more
Unknown
Primary person involved - full name
Primary person involved - job title or role
Employer or company (if contractor)
Did anyone sustain an injury or illness?
Yes
No
Injured body part(s)
Please Specify:
Nature of injury or illness
Please Specify:
Was first aid provided?
Yes
No
Treatment type
None
Self-treated
On-site first aid
Off-site clinic/GP
Emergency department/hospital
Admitted to hospital
Not applicable
Unknown
Did the person return to work the same shift?
Yes
No
Describe what happened
Describe any events or conditions leading up to the incident
Equipment, materials, or substances involved
Environmental or weather conditions (if relevant)
Contributing factors (select all that apply)
Please Specify:
Personal protective equipment in use at the time
Please Specify:
Witness names and contact details
Were there any witnesses?
Yes
No
Immediate actions taken
Please Specify:
Time of first notification (e.g., 15:05)
External case or report numbers (if any)
Who was notified?
Please Specify:
Immediate corrective actions completed
Further actions required
Target completion date for further actions
Responsible person for follow-up
How likely is a similar incident to occur again without further action?
0 Not at all likely
1
2
3
4
5 Extremely likely
Reviewer name
Review date
Incident classification
Recordable injury/illness
First aid only
Near miss
Property damage
Security incident
Environmental incident
Vehicle incident
Unknown
Other
Please Specify:
Estimated financial impact
None
Under 500
500-2,000
2,001-10,000
Over 10,000
Unknown
Reporter signature
Signature date
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 staff incident report form template for FormCreatorAI

When to use this form

Use this form after any workplace event that harms people, property, or operations. Typical cases include slips or strains, a near miss around machinery, harassment between coworkers, damage to company equipment, or a data or access issue. HR, managers, and safety leads benefit from a clear, time-stamped record that guides next steps and compliance. For injuries, pair this with the Employee accident/incident report form to support workers comp and corrective action. If theft, assault, or vandalism occurred, you may also need a Police incident report form. For cyber or outage-related events managed by IT, log technical details in the Crowdstrike cyber attack report form. The outcome is a consistent account that speeds decisions, follow-up, and prevention.

Must Ask Staff Incident Report Questions

  1. What happened and where did it occur?

    Specific facts and the exact location help you identify hazards, pull camera footage, and map patterns. Clear detail reduces guesswork and speeds corrective action.

  2. When did the incident begin and end?

    Date and time anchor the timeline and confirm shift coverage. Accurate timing protects compliance, notice periods, and insurance reporting.

  3. Who was involved and who was affected?

    Names, roles, and contact details guide HR outreach and witness follow-up. If medical care was needed, also submit the Employee accident report form to document treatment.

  4. What immediate actions did you take?

    Recording first aid, isolation of equipment or systems, and who you notified shows due diligence. It highlights quick wins and gaps to address in training or maintenance.

  5. What evidence and witnesses can you provide?

    Photos, logs, emails, and CCTV sources plus witness names make the report verifiable. Strong evidence supports fair decisions and defends audits or claims.

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