Workplace Accident and Safety Incident Report

Thanks for reporting this. The details you provide help us understand what happened and prevent it from happening again. Your responses are completely confidential and anonymized. This should take about 5-6 minutes — please answer as accurately as you can, even if some parts are hard to recall.

When did the incident occur?

Where exactly did this happen (building, floor, workstation, vehicle, etc.)?

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

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)

How severe was this incident overall?

Describe what happened, step by step: what you were doing right before, what occurred during the incident, and what happened immediately after.

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• Unclear or outdated procedures

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.

Rate the following conditions at the time of the incident:

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

Please confirm the accuracy of this report before submitting.

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

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.