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Incident Report Form
Reporting Party Employee Name
Reporting Party E-Mail
What type of Incident are you reporting?
Safety Incident:
Definition: A safety incident refers to an event that has caused, or had the potential to cause, injury, harm, or damage in the workplace. This encompasses accidents, near misses, and safety hazards.
Examples: An employee slipping and falling due to a wet floor, machinery malfunction leading to a near miss, a fire breaking out in the workplace.
Health Incident:
A health incident involves the onset or exacerbation of illnesses or medical conditions caused or worsened by workplace conditions or activities. These can be acute or chronic.
Examples: An employee developing respiratory issues from exposure to hazardous chemicals, repetitive strain injury due to poor ergonomic practices, stress-related illnesses from workplace conditions.
Security Incident:
A security incident in the workplace refers to events that compromise or threaten the physical or informational security of the workplace, its premises, assets or its personnel. This includes breaches of physical security, data security, and threats to personal safety.
Examples: Unauthorized access to restricted areas, data breaches involving sensitive company information, theft or vandalism, threats or acts of violence in the workplace.
Incident Type as per above definition
*
Incident Type as per above definition
A
Safety
B
Security
C
Health
Date of Incident
*
Description of Incident
*
Cause of the Incident
Immediate Actions Taken
Corrective Measures Taken
Submit