Report details
| Field | Fill in |
|---|---|
| Report number | [Number] |
| Date and time of the event | [Date] [Time] |
| Location (site, area, machine or room) | |
| Reported by and role | |
| Date and time reported | |
| Person or persons involved | [Names and roles, or 'None' for a near miss] |
| Witnesses | |
| Type | Near miss / Injury / Illness / Property damage / Vehicle / Fire / Environmental / Other |
What happened
- Describe what happened in a few lines, in the order it took place.
- What was the person doing, and what equipment, material or vehicle was involved?
- What went wrong, or could have gone wrong?
- Was anyone hurt? If yes: who, which part of the body, and what medical attention was given?
- Was there damage to property, a product or the environment? [Describe.]
- Attach photographs, a sketch or CCTV reference if available.
Immediate action and severity
- First aid or medical help given, by whom and when.
- Area made safe: Yes / No. What was done?
- Work stopped or restarted, and who decided.
- Worst likely outcome if this had gone differently: Minor / Serious / Major.
- Likelihood of it happening again: Unlikely / Possible / Likely.
- Manager and safety lead informed at: [Time].
Investigation
| Question | Finding |
|---|---|
| Why did it happen? (ask why up to five times) | |
| Was a procedure, training or instruction missing or not followed? | |
| Did equipment, layout, lighting or workload play a part? | |
| Has something like this happened before? | |
| Root cause |
Corrective and preventive actions
Closed by: ____________ Date: ____________ Reviewed with the safety committee or lead on: ____________
Injuries and some events may have to be reported to authorities within set times. Check what applies to you with your legal adviser, and write the steps and timelines into your own procedure.
| Action | Owner | Due date | Status | Checked by |
|---|---|---|---|---|
| [Fix the cause] | ||||
| [Retrain or brief staff] | ||||
| [Share what was learned with other teams] |
A starting point, not legal advice. Check the final wording against your contracts and the rules of your state, and have a qualified professional review it before you issue it.