INCIDENT REPORT TEMPLATE Last Updated: February 2026 ═══════════════════════════════════════════════════════════════ INCIDENT INFORMATION ═══════════════════════════════════════════════════════════════ Report Number: _________________________ Project Name: _________________________ Project Number: _________________________ Date of Incident: _________________________ Time of Incident: _________________________ Location on Site: _________________________ Reported By: _________________________ Date Reported: _________________________ ═══════════════════════════════════════════════════════════════ PERSON(S) INVOLVED ═══════════════════════════════════════════════════════════════ Name: _________________________ Age: _________________________ Trade/Position: _________________________ Company: _________________________ Years of Experience: _________________________ Injury Type (if applicable): _________________________ ═══════════════════════════════════════════════════════════════ INCIDENT DESCRIPTION ═══════════════════════════════════════════════════════════════ What Happened: _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ Sequence of Events: 1. _________________________________________________________ 2. _________________________________________________________ 3. _________________________________________________________ 4. _________________________________________________________ Immediate Cause: _____________________________________________________________ _____________________________________________________________ Contributing Factors: _____________________________________________________________ _____________________________________________________________ ═══════════════════════════════════════════════════════════════ INJURY DETAILS (if applicable) ═══════════════════════════════════════════════════════════════ Body Part Affected: _________________________ Nature of Injury: _________________________ Severity: ☐ Minor ☐ Moderate ☐ Serious ☐ Critical Medical Treatment Required: ☐ Yes ☐ No Hospital/Clinic Name: _________________________ Treatment Date: _________________________ ═══════════════════════════════════════════════════════════════ WITNESSES ═══════════════════════════════════════════════════════════════ Witness 1: Name: _________________________ Contact: _____________________ Statement: ___________________________________________________ _____________________________________________________________ Witness 2: Name: _________________________ Contact: _____________________ Statement: ___________________________________________________ _____________________________________________________________ Witness 3: Name: _________________________ Contact: _____________________ Statement: ___________________________________________________ _____________________________________________________________ ═══════════════════════════════════════════════════════════════ PROPERTY DAMAGE ═══════════════════════════════════════════════════════════════ Description of Damage: _____________________________________________________________ _____________________________________________________________ Estimated Cost: $_________________________ Equipment/Materials Affected: _____________________________________________________________ ═══════════════════════════════════════════════════════════════ ROOT CAUSE ANALYSIS ═══════════════════════════════════════════════════════════════ Immediate Cause: _____________________________________________________________ _____________________________________________________________ Root Cause: _____________________________________________________________ _____________________________________________________________ Contributing Factors: 1. _________________________________________________________ 2. _________________________________________________________ 3. _________________________________________________________ ═══════════════════════════════════════════════════════════════ CORRECTIVE ACTIONS ═══════════════════════════════════════════════════════════════ Immediate Actions Taken: 1. _________________________________________________________ 2. _________________________________________________________ 3. _________________________________________________________ Preventive Actions Planned: 1. _________________________________________________________ Responsible: _________________________ Due: _______________ 2. _________________________________________________________ Responsible: _________________________ Due: _______________ 3. _________________________________________________________ Responsible: _________________________ Due: _______________ ═══════════════════════════════════════════════════════════════ PHOTOS & DOCUMENTATION ═══════════════════════════════════════════════════════════════ Photo References: _________________________ Other Documentation: _________________________ ═══════════════════════════════════════════════════════════════ SIGNATURES ═══════════════════════════════════════════════════════════════ Prepared By: _________________________ Date: ___________ Reviewed By: _________________________ Date: ___________ Approved By: _________________________ Date: ___________ ═══════════════════════════════════════════════════════════════ OSHA RECORDKEEPING ═══════════════════════════════════════════════════════════════ OSHA Recordable: ☐ Yes ☐ No If Yes, record on OSHA 300 Log