Incident report template

Report an injury, near miss, damage or security problem while it is fresh: what happened, who was hurt, who saw it and what was done.

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What are you reporting? (required)

Check all that apply.

Date it happened (required)

Time it happened

Where did it happen? (required)

Site, building and the exact spot: “Loading dock 2, by the roller door”.

What was going on just before?

The task, and any tools, equipment, vehicles or chemicals in use.

What happened? (required)

Facts, in the order they happened. Say what you saw, not who was to blame.

23 questions · about 3 min · logic · file upload · signature

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Print it as a PDF Word version

Change the questions in Word, then print.

What you get back

Every response lands in your results the moment it is sent. Turn on email notifications and each one arrives like this, and the same answers become a row in your spreadsheet.

From PulseFormCreator

Subject New response to Report an incident

What are you reporting?: An injury or illness
Date it happened: 21 Sep 2026
Time it happened: 14:20
Where did it happen?: Warehouse 2, loading dock, beside roller door B
What was going on just before?: Unloading a pallet of paint cans with the hand pallet jack.
What happened?: The jack’s wheel caught on the dock plate lip and the pallet tipped. A 2-gallon can fell and struck Jordan’s left foot. He was wearing safety boots.

and 13 more answers

A sample email with made-up answers.

submitted_at	What are you reporting?	Date it happened	Time it happened	Where did it happen?	What was going on just before?
22 Sep 2026 09:41	An injury or illness	21 Sep 2026	14:20	Warehouse 2, loading dock, beside roller door B	Unloading a pallet of paint cans with the hand pallet jack.

Export to CSV or Excel, or send responses to Google Sheets, Notion, Airtable, Slack or a webhook. All free.

What happens after someone submits

Turn these on in the Workflows tab. AI triage runs only on forms where you turn it on, and answers to contact questions, files and signatures are never sent.

Submitted
A report comes in

AI triage gives it a P1–P3 priority, a one-line summary and tags: 100 a month free, unlimited on Pro.
Straight after

The safety lead gets an email with a PDF of the report attached, so nobody waits for the next meeting.
The manager follows up

If the reporter left an email, reply from their response in Results; their answer comes back to the same thread.

Set this up when you use the template

What this form asks, and why

An incident report records, in order, when and where it happened, what happened, who was hurt and how, who saw it and what was done straight away. Write it the same day, give facts rather than blame, and sign it; a supervisor then reviews it and signs off the follow-up.

The last column shows how often real incident report forms ask for it.

Question	Why it is there	Real forms
What are you reporting? Required	Near misses sit beside injuries: 7 of 17 forms ask for them.	8 of 17 forms
Date it happened Required	On 17 of 17 forms. The timestamp also shows how soon it was reported.	17 of 17 forms
Time it happened	Shifts, lighting and fatigue all depend on it.	16 of 17 forms
Where did it happen? Required	The exact spot. Fills in from ?site= on a posted QR code.	15 of 17 forms
What was going on just before?	OSHA’s Form 301 asks the same: the task, and the tools in use.	9 of 17 forms
What happened? Required	On every form.	17 of 17 forms
What could have happened? Required Only when “What are you reporting?” includes “A near miss: nobody was hurt, but someone could have been”	Penn State’s question: what the near miss nearly did.	7 of 17 forms
Name of the person hurt or ill Required Only when “What are you reporting?” includes “An injury or illness”	Often not the reporter, so your browser will not autofill it.	15 of 17 forms
They are Required Only when “What are you reporting?” includes “An injury or illness”	Employees, contractors and visitors are recorded differently.	6 of 17 forms
Type of injury or illness Required Only when “What are you reporting?” includes “An injury or illness”	Checkboxes sort and count in your export; free text does not.	13 of 17 forms
Part of the body affected Required Only when “What are you reporting?” includes “An injury or illness”	“Left wrist”, not “arm”, as St. Lawrence University asks.	7 of 17 forms
What treatment did they get? Required Only when “What are you reporting?” includes “An injury or illness”	Hospital answers end on a phone-now screen.	11 of 17 forms
Did they stop work or go home because of it? Only when “What are you reporting?” includes “An injury or illness”	Days off decide much of what is recordable or reportable.	6 of 17 forms
What was damaged, and how badly? Required Only when “What are you reporting?” includes “Damage to property or equipment”	Shown only when damage is checked.	6 of 17 forms
Who saw it?	Names and numbers, blank if nobody saw.	15 of 17 forms
Photo of the scene, equipment or damage	The wet floor or the missing guard, before anyone tidies up.	5 of 17 forms
What was done straight away?	Only 5 of 17 forms ask. The same-day fix, kept apart from the lasting one below.	5 of 17 forms
What would stop it happening again?	The reporter’s idea, kept apart from what the manager decides.	11 of 17 forms
Your name Required	May not be the person hurt.	9 of 17 forms
Your phone number	For the manager’s follow-up call.	9 of 17 forms
Your email	Optional. Lets the manager reply from Results.	4 of 17 forms
Which supervisor or manager have you told?	Shows a manager knows.	2 of 17 forms
Your signature	Optional, so a near miss still takes a minute.	8 of 17 forms

What we left out

Date of birth and gender. 5 of 17 forms ask for a birth date. A first report does not need it.
A root-cause checklist. Causes are the manager’s job. Asking the reporter invites blame.
A body outline to mark. Hard to mark with a thumb.

What 17 real incident report forms ask

How many include each field, from forms organizations use today. Part of the Form Field Index.

Date of the incident 17 of 17
Description 17 of 17
Time of the incident 16 of 17
Name of the person involved 15 of 17
Where it happened 15 of 17
Witness 15 of 17
Type of injury 13 of 17
Medical treatment 11 of 17

Read September 2026 · US 12, UK 5 · Sources

Penn State University (Physical Plant and Auxiliary Safety Offices) · university, US
Columbia University Irving Medical Center (Facilities Management) · university (contractor incidents on site), US
Stewards Individual Placements / Stewards Legacy · nonprofit conservation corps, US
United Charitable · nonprofit (insurer's incident report form, filled in with its own details), US
ABC Adult School · adult school, US
Western Carolina University (Campus Recreation and Wellness) · university, US
The Evergreen State College (Environmental Health and Safety) · public college, US
Clarke University (Safety and Security) · university, US
Pleasant Valley Recreation and Park District · park and recreation district, US
DeSoto County Schools · school district, US
Community Action House · nonprofit (food pantry and community services), US
St. Lawrence University · university, US
Nottingham Trent University · university, UK
Girlguiding · charity (youth organization), UK
Greenwich and Lewisham u3a · community organization, UK
Warwickshire County Council (Health, Safety and Wellbeing Service) · county council, UK
Stockport Council (Greenspace volunteer tasks) · local council, UK

How the form changes as people answer

Most people see a shorter form. These questions and screens only appear when an answer calls for them.

When “What are you reporting?” includes “A near miss: nobody was hurt, but someone could have been”

shows “What could have happened?”
When “What are you reporting?” includes “An injury or illness”

shows “Name of the person hurt or ill”, “They are”, “Type of injury or illness”, “Part of the body affected”, “What treatment did they get?” and “Did they stop work or go home because of it?”
When “What are you reporting?” includes “Damage to property or equipment”

shows “What was damaged, and how badly?”
When “What are you reporting?” includes “An injury or illness” and “What treatment did they get?” is “Taken to the hospital” or “Admitted to the hospital overnight”

shows the “Now phone your safety contact” ending

Make it yours

A QR code at each site

Link posters by the first aid kit to ?site=Warehouse 2.
Your number on the hospital screen

Edit the “Now phone” ending with your safety contact’s name and number.
Require a signature

Turn on Required for “Your signature” if your policy says every report is signed.

Good practice and the law

This is general information, not legal advice. Rules differ by country and state, so check anything important where you operate.

US
Tell OSHA of a work-related death within 8 hours; an in-patient hospitalization, amputation or lost eye within 24. 29 CFR 1904.39
US
Recordable cases go on the OSHA 300 log and Form 301 within seven calendar days. 29 CFR 1904.29
UK
Report more than seven days off normal duties within 15 days; record more than three in your accident book. HSE, RIDDOR
Australia
Notify your WHS regulator immediately of a death, serious injury or illness, or dangerous incident. Safe Work Australia, incident notification

Questions about this template

Does a near miss need a report?

Some must go to the regulator: RIDDOR’s dangerous occurrences and Australia’s dangerous incidents can hurt nobody.

Can this replace OSHA Form 301?

Not as it stands: an equivalent needs everything 301 asks, such as the date hired. Add those questions, or copy each case across.

Should the injured person fill it in, or a supervisor?

Whoever saw it or heard first. The injured person’s name is its own question, so a colleague can report for them.

Is there a version for accidents, schools or security?

Yes, above the preview: an accident version with a vehicle section, a school one that names the student and when a parent was told, and a security one with the police reference.

Which form do you need?

Not quite the job? One of these may fit, or browse all inspection, report and evaluation forms.