Incident Reporting Software

How to Use & Customize The Templates

The forms can be filled out on your computer or printed out and filled in by hand. You can change the wording and content in t
drop down boxes so that they better reflect issues or processes in your workplace. To change the content, simply find the
heading for the field you’d like to modify – for example, “Incident Status”. The fields in the drop down menu are listed below ea
heading. Delete, add or modify the fields to suit your needs.

Pick List Values

Incident Status Environmental Incident Type
Fatality Air Exceedence
Job Transfer Water Exceedence
Lost Time Spill
Minor/ First Aid Other
Off-site Medical
Restricted Work
Method of Contact
Employee Status Fax
Contractor Email
FTE Phone
PTE
Temp

Primary Type of Injury

Amputation
Bruise/Contusion
Burn
Carpal Tunnel
Chemical Burn
Chemical Exposure
Concussion
Crushing
Dermatitis
Dislocation
Electric Shock
Foreign Body
Fracture
Hearing Loss
Heat Stress
Hernia
Infection
Inhalation
Laceration
Sprain/Strain
Primary Body Part Affected
Abdomen
Ankle
Arm
Back
Chest
Ear
Elbow
Eye
Face
Finger
Hand
Groin
Foot
Head
Hip
Internal
Knee
Leg
Neck
Shoulder
Skin
Toe
Wrist

Primary Cause of Injury

Caught Between
Caught In
Caught On
Contact With
Equipment Failure
Fall From Elevation
Fall Same Level
Overexertion
Slip/Trip
Stuck Against
Struck By

State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
SC
SD
TN
TX
UT
VA
VT
WI
WV
WY
ftware

nge the wording and content in the

the content, simply find the
down menu are listed below each

Region
Americas
APAC
EMEA
India

Who reported the complaint

Alternative Worker
Employee
Other

Person Tpye
Alternative Worker
CWR
Employee
Other

Organization
Channel
Distributor
End Consumer
Engineering
Executive
Finance
Government Entity
Human Resources
Information Technology
Internal Audit
Legal
Manufacturing
Marketing
NGS
Operations
Other
Partner
Product Operations
Professional Services
Sales
SAS
USPS
Workplace Resources

Case Category
Air Quality/Odor Complaint
Alarms
Annoying/Threatening Communication
Arson
Assault & Battery
Audit/Inspection
Bomb Threat
Burglary
Controlled Substance
Counterfeit Currency
Demonstrations/Picketing/Protests
Evacuation
Extortion
Fire/Smoke - Building, Vehicle, Other
Gambling
Hate Crimes
Health & Safety
Law Enforcement
Missing Property
Robbery
Security/Terror Alert
Social Engineering Scheme
Terrorist Attack
Theft Under $25k
Theft Over $25k
Travel Security Support
Trespassing
Vandalism
Case Information
Company
Event Date
Time

Brief Summary

Detailed Description

Incident Information
Incident Status
OSHA Recordable Yes

Worker's Compensation Claim Filed Yes

Employee Information
Employee Number
First Name
Last Name
Supervisor Name
Date of Birth (MM/DD/YYYY)
Gender Female

Job Title
 Employee Status
Will Pay for Date of Injury Yes

Time Employee Began Work

Time of Injury
Last Day Worked
Date of Disability
Date Employer Notified
Date Employee Returned to Work

Accident Information
Primary Type of Injury
Secondary Type of Injury
Primary Body Parts Affected
Secondary Body Parts Affected
Primary Cause of Injury
Secondary Cause of Injury
Did injury occur on employer's premises? Yes

Were safeguards provided? Yes

Were safeguards used? Yes

Employee's Initial Treatment

Medical Information
Physician/ Health Care Provider
Hospital Name
Address
City
Hospital Overnight? Yes

Contact/Agency/Witness Information (Optional)

Contact Type
First Name
Last Name
Title
Company/Agency Name
Phone
Email
Notes
Incident Report Template
This is a free template provided by i-Sight - the makers of incident reporting
software.
www.customerexpressions.com

Briefly describe the key events/impact of the incident

Include, if applicable, any contributing factors; the initial response; source/equipment involved; the

pollutants/contaminates released; measured or estimated quantities applicable permit limits; operational

conditions prior to, during and after the incident; and actual/potential environmental impacts.

Yes No

Yes No

Female Male
 Yes ✘ No

Yes No

Yes No

Yes No

Apt./Suite
Postal Code
State
Yes No

rmation (Optional)
Witness Reported By Involved Agency Other
ext.
Case Information
Company
Event Date
Time

Brief Summary

Detailed Description

Incident Information
Incident Type
Environmental Incident Type
Location
Unit
Equipment
Total Duration (D,H,M)
Date Discovered
How Discovered
Investigation of the Incident
Actual Repeat Incident?
Potential Trend/Pattern

Incident Notification Summary

 Division Director
Method of Contact
Date
Project Manager
Method of Contact
Date
ESS
Method of Contact
Date
State Agency
Method of Contact
State Agency Case Number
Date
Local Agency
Method of Contact
Local Agency Case Number
Date
EPA
Method of Contact
EPA Case Number
Date

Contact/Agency/Witness Information (Optional)

Contact Type
First Name
Last Name
Title
Company/Agency Name
Phone
Email
Notes
 Incident Report Template
This is a free template provided by i-Sight - the makers of incident reporting
software.
www.customerexpressions.com

Briefly describe the key events/impact of the incident

Include, if applicable, any contributing factors; the initial response; source/equipment involved;

pollutants released; measured or estimated quantities applicable permit limits; operational

conditions prior to, during and after the incident; and actual/potential environmental impacts.

on
Environmental

In Progress Complete

Yes No

Yes No

on Summary
Witness Information (Optional)
Witness Reported By Involved Agency Other
 Incident Report Template
This is a free template provided by i-Sight - the makers of incident
reporting software.
www.customerexpressions.com

What type of case is this? Security

Date and Time Reported
Date Occurred From
Date Occurred To
Department
Region
Sub Region
City

What is the case about?

Case Category
Case Sub Category
Who reported the complaint? Alternative Worker 1

Reporting Party
Employee Number
Name
Email
Phone
Address 1
Address 2
City
State
Zip/Postal Code
Country
Job Title
Person Type
Location
Building
Initial Information
 Region
Organization

Supervisor Details
Employee Number
Name
Email
Phone
Address 1
Address 2
City
State
Zip/Postal Code
Country
Job Title
Person Type
Location
Building
Region
Organization
 Incident Report

Report Date/Time

Confidentiality

Point of Contact

Name:
Title:
Telephone:
Fax:
E-mail:

Summary

Incident Details

Notification Process

Technical Details & Fix

Actions

Conclusion
 Incident Report

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be granted to those with a business related need-to-know. If you have any questions
pertaining to the distribution of this document, please contact COMPANY PERSON.