Incident report form template

What’s inside

Seven pages, split into two clear parts.

Part A, filled in by the person reporting. Incident type, a short description, location, dates and times, who reported it and who they told, witness details, and injury details including treatment provided.

Part B, the manager review. What happened in full, causal factors, root cause analysis, corrective actions, consequence rating, and whether a detailed investigation is needed.

Causal factors, properly listed

The weak point in most incident forms is the cause section. A blank box invites a one-line answer, and the one-line answer is usually “worker error”.

This form gives you 25 specific factors across three groups: equipment, task and work environment, and management systems. Things like absent guarding, time pressure, inadequate supervision, poor maintenance schedules and operational goals that conflict with safety goals.

Tick everything that contributed. More than one box will usually apply, and that is the point.

Root cause analysis you will actually complete

“Ask why repeatedly” gets skipped. Five numbered boxes get filled in.

There is also a line reminding whoever fills it in that “the worker was careless” is a symptom, not a root cause. If that is where your analysis stops, the same incident is coming back.

Know what has to be reported

Some incidents must go to the WHS regulator immediately, and the site preserved until they say otherwise. A death, a serious injury or illness, and dangerous incidents like uncontrolled explosions, electric shock or structural collapse.

That sits in a callout on page one, because it is the thing people miss when they are rattled.

Fill it in on screen, or print it

The PDF is fully editable. Consequence ratings and yes/no questions are radio buttons, so you get one answer. The tick-all-that-apply sections let you tick as many as apply.

Signature lines are left blank for wet signing.

A template is a starting point

This is a well-built form based on Australian WHS practice. It is not an investigation methodology, and it does not replace a trained investigator for a serious incident.

If something significant has happened at your workplace, get help early. BWC Safety runs ICAM incident investigations, and our consultants each bring over 20 years of senior management experience across a wide range of industries.