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Questionnaire template

Incident Report

Collects the details, causes, severity and prevention ideas for a workplace or site incident from those involved.

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Questions in this template

Incident Basics

  1. Thank you for reporting this incident. A clear account helps us learn from what happened and keep people safe.

  2. When did the incident happen?

    Open answer

  3. Where exactly did it happen? Include the building, area or room if you can.

    Open answer

  4. Which category best describes the incident?

    Choose one from a list:

    • Accident
    • Near miss
    • Safety rule breach
    • Damage to property
    • Injury
    • Other

  5. Please describe the type of incident.

    Condition: Only when the category is Other

    Open answer

What Happened

  1. In your own words, what happened?

    Open answer

  2. What was done straight after the incident?

    Open answer

Causes and Impact

  1. What contributed to the incident? Select all that apply.

    Choose any that apply:

    • Human error
    • Equipment failure
    • Environmental conditions
    • Procedure not followed
    • Other
    • Not known

  2. What other factor contributed?

    Condition: Only when Other is selected

    Open answer

  3. How serious was the incident?

    Choose one:

    • 1 - Minor
    • 2
    • 3
    • 4
    • 5 - Severe

  4. Was anyone injured?

    Choose one:

    • Yes
    • No
    • Not sure

  5. Please describe the injuries and who was affected.

    Condition: Only when someone was injured

    Open answer

Preventing a Repeat

  1. What could be done to stop something similar from happening again? List up to three measures.

    Open answer

  2. Is there anything else we should know about this incident?

    Open answer