Workplace incident report

Document incidents with time, place, injuries, witnesses, evidence, and a signature.

Use this template

Report the incident as soon as possible, even if it seems minor. Accurate details help prevent it from happening again.

Name of person reporting

Nombre

Apellido

Role

Contact phone

Date of incident

Approximate time

Exact location of the incident

Type of incident

Describe what happened, step by step

Was anyone injured?

Yes No

Name of the injured person

Type of injury and body part affected

Medical attention received (first aid, transfer, etc.)

Were there witnesses?

Yes No

Witness names and contact details

Photos or evidence of the scene

Max 25 MB per file · jpg, jpeg, png, pdf, mp4

Immediate actions taken

Signature of the reporter

Sign here

I confirm this report is truthful to the best of my knowledge.

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