Q01
Message
All templates
Workplace Accident and Safety Incident Report
Captures the facts of a workplace accident or near-miss — what happened, where, how severe, and what conditions contributed — for safety officers and EHS teams. An AI follow-up interview reconstructs the sequence of events in the employee's own words and probes for root causes that a checklist alone would miss.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
14 questions · ~7 min
Q02
DateRequired
When did the incident occur?
Q03
Short TextRequired
Where exactly did this happen (building, floor, workstation, vehicle, etc.)?
Q04
Multiple ChoiceRequired
Which best describes the type of incident?
- Slip, trip, or fall
- Struck by or against an object
- Equipment or machinery malfunction
- Chemical or hazardous material exposure
- Vehicle or transportation incident
- Repetitive strain or ergonomic injury
- Near miss (no injury or damage occurred)
- Other
Q05
Multiple ChoiceRequired
What was the outcome of the incident?
- Injury requiring medical treatment
- Injury not requiring medical treatment
- Property or equipment damage only
- No injury or damage (near miss)
Q06
Rating ScaleRequired
How severe was this incident overall?
Range: 1 – 5
Min:Minor - no lasting impactMax:Severe - critical or life-threatening
Q07
Long TextRequired
Describe what happened, step by step: what you were doing right before, what occurred during the incident, and what happened immediately after.
Q08
Multiple Choice
Which of the following do you think contributed to this incident? Select all that apply.
- Equipment failure or malfunction
- Inadequate training
- Fatigue or excessive workload
- Unsafe or hazardous conditions
- Time pressure
- Communication breakdown
- Personal protective equipment not used or unavailable
- Unclear or outdated procedures
Q09
AI Interview
Reconstruct the exact sequence of events leading up to, during, and after the incident, anchoring on any contributing factors the respondent selected (e.g. fatigue, unclear procedures, missing PPE). Probe for the root cause rather than just the immediate trigger: ask what would have needed to be different for this not to happen, and whether similar near-misses have occurred before. If the description is vague or minimizes the severity, gently ask for specifics on timing, location, and who else was present or affected.
Q10
Matrix
Rate the following conditions at the time of the incident:
5 rows × 4 columns
- Lighting
- Housekeeping / walkway conditions
- Equipment condition and maintenance
- Staffing levels at the time
- Noise or distraction level
Columns: Good · Fair · Poor · Not applicable
Q11
Multiple ChoiceRequired
Who have you reported this incident to so far?
- Direct supervisor or manager
- Safety officer / EHS team
- Human resources
- Have not reported to anyone yet
- Other
Q12
ConsentRequired
Please confirm the accuracy of this report before submitting.
Q13
Multiple Choice
Which department do you work in? (Template note: replace this list with your own department names before launching.)
- (Replace with Department A)
- (Replace with Department B)
- (Replace with Department C)
- Other
- Prefer not to say
Q14
Message
Thank you for submitting this report. It will be reviewed by the safety team to investigate the incident and identify any corrective actions needed to prevent recurrence.
What’s included
AI follow-ups
Adaptive probes on open-ended answers that pull out detail a static form would miss.
Attention checks
Built-in safeguards against rushed answers and low-quality respondents.
AI-drafted copy
Wording, ordering, and branching written by the AI — tuned to your research goal.
Auto report
Themes, quotes, and a plain-English summary write themselves once responses come in.
How it compares
We reviewed the closest templates from other survey tools. Here’s what they do well — and where this template goes further.
Why this template
- Goes beyond a static form: after the employee describes what happened, an AI follow-up interview reconstructs the exact sequence of events in their own words and probes for root causes a checklist alone would miss
- Combines structured fields (incident type, outcome, severity rating, contributing factors, a conditions matrix) with open-ended narrative capture, so safety officers get both quantifiable data and context
- Includes a consent step confirming accuracy before submission and a reporting-chain question, supporting documentation integrity for EHS review
- Report is auto-generated from responses, reducing manual compilation work for the safety team reviewing each incident
Jotform
Employee Accident/Incident Report Form TemplateA fielding-ready static form template covering standard incident-report fields, built on Jotform's drag-and-drop form builder with e-signature and file upload support. Good for basic documentation and routing, but it does not adapt questions based on answers. It relies on the respondent filling out fixed fields rather than being interviewed.
What it does well
- Highly customizable drag-and-drop form builder
- Supports e-signatures and file/photo uploads common in incident documentation
- Large template library for quick setup
Where it falls short
- No adaptive AI follow-up interview to reconstruct the event sequence in the employee's own words
- No automated per-response quality scoring
- No voice AI interview option
Typeform
Workplace Accident Report Form TemplateA conversational one-question-at-a-time template well-suited for a friendlier reporting experience. It's still a fixed sequence of pre-written questions, not a dynamic interview, so it can't probe deeper based on a specific employee's answer. Reporting relies on Typeform's standard results dashboard.
What it does well
- Polished, conversational question-by-question UI that may reduce reporting friction
- Logic jumps for branching between question paths
- Mobile-friendly design
Where it falls short
- No AI-driven follow-up questioning to dig into root causes beyond the scripted flow
- No automated quality scoring of individual responses
- No published methodology or prompt transparency (nor would it need one, since there's no AI interview)
SurveyMonkey
Accident Report Form TemplateA standard survey-platform template for capturing accident details, benefiting from SurveyMonkey's broad analytics and reporting tools. It is a static question set aimed at general survey use rather than a purpose-built AI interview experience for reconstructing incidents. Good for simple tallying of incident types, less suited to nuanced root-cause narratives.
What it does well
- Established analytics and cross-tabulation reporting
- Easy template customization within a familiar survey builder
- Broad integration ecosystem
Where it falls short
- No adaptive AI interview to reconstruct sequence of events or probe root causes
- No voice AI interview option
- No automated per-response quality scoring
SurveySparrow
Accident Report Form TemplateA chat-style survey template that presents accident-report questions conversationally, which can feel more approachable than a traditional form. However, the conversational UI is still a fixed question sequence rather than an AI-driven interview that adapts based on the specific incident described. It's a template for fielding, not a guide or blog.
What it does well
- Conversational chat-like interface for a friendlier reporting tone
- Supports skip logic for basic branching
- Template ready to field with minimal setup
Where it falls short
- No true adaptive AI follow-up interview probing root causes beyond scripted branching
- No voice AI interview capability
- No automated quality scoring of individual responses
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.