Incident Report Form

Please use this form to report health and safety hazards and/ or incidents that have occurred within your workplace. We require an honest account of what has happened to ensure we find a fair and suitable conclusion/ resolution. Please report the incident in full and the factors that contributed to the incident.

First Name *

Last Name *

Contact Number *

Email Address *

Occupation *

Organisation & Location *

Date of Incident *

Time of Incident *

Incident Details *

Immediate Action Taken (if any) *

Has the incident been reported to management or anyone else within the business?

Were there any witnesses?

I acknowledge that everything stated above is correct to my knowledge and is an accurate account of the events that occurred.

Signature *

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Date *

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