INCIDENT REPORT FORMAT

Paragraph 1: Introduction

What to include
– state your purpose or reason for writing (can come at the end or beginning)

Examples of Purpose vocabulary

The purpose of this report is to explain the circumstances surrounding the injury received by
John Brown ……

The purpose of this report is to provide an account of (WHAT HAPPENED)

The purpose of this report is to describe the accident that led to the death/ hand injury/chemical
spill/fire/ etc.

– Summarize the 4 W facts

 WHAT happened (outcome of accident and/or nature of injury, if it is an injury report)

 WHO was injured or nearly injured (Use correct name of person if you are writing as an eye-
witness; use ‘I’ if writing about your own injury. Read the scenario/case study question to be
sure you have understood the point of view you are writing from.)
 WHERE (the site of the accident– if on the premises, state the building or space where it
occurred and use the phrase ‘on the premises’; if the accident occurred outside of company
grounds, state the accident site, (Highway 2000 Project site or Digicel Building Construction
Site, 33 Dunmore Street, Kingston 10) as well as name of building or site and street address)
 WHEN (state the exact time period if it happened within a 24 hour period (you would have
written the date in the memo heading already. Also state the time of the accident/injury/death;
E.g. at 9:15 this morning)

BODY

Description of Accident

Paragraph 2 : Set the context of the incident for the readers, your simulated reader (supervisor).
State what time you arrived at work. What task you were assigned. Provide details. Mention any
other members of your work team.(by name if it is less than five, by number if it is more)

Paragraph 3. BEFORE THE ACCIDENT: Devote this paragraph to a description of the events
leading up to the incident time.
Paragraph 4: DURING THE INCIDENT: Describe the moment when man encounters hazard.
Use spatial description here to identify the location of the person at the time, the location of the
hazardous condition; any hazardous behavior/activity that preceded the accident. Name any
machine, tools, substances, and equipment involved. Describe what you see and how you
observed it. Where were you and what were you doing when you were alerted ton the dangerous
occurrence?

Paragraph 5 AFTER THE INCIDENT: What was your first response to the injury? If it is an
eye witness report state what first aid you rendered or sought for the injured person. What
medical assistance did the person receive, if any? What medical facility was person transported
to, time of arrival, his state of consciousness and body part, state:

 what first aid you rendered or sought for the injured person.
 what medical assistance the person received, if any.
 what medical facility the injured person was transported to
 the time of arrival
 his state of consciousness, and
 body part injured.

State the outcome of the accident and the direct cause of the injury/ accident.

Examples:
 Mr. Jones’ accident was not intentional and resulted when he stepped on a loose rung of a
defective ladder that had not been inspected before use.
 Mr. Thomas suffered a head injury because he was not wearing a hard hat at the time.
 According to the medical team at St Joseph’s Hospital, the cause of death was cardiac arrest,
which he suffered when 2000 volts of electricity passed through his body when the metal
ladder he was standing on came into contact with high voltage overhead power lines.
SAMPLE REPORT 1

Memorandum

To: Roland Troy – Supervisor

From: Romaine Barnes – Welder/Fabricator
Date: January 24, 2018

Subject: Team Member Injured in Workshop accident

The purpose of this report is to inform you of an accident involving a member of our work team
in the Welding Shop yesterday which resulted in him receiving burn injuries.

On Monday, the 23rd of January, at about 1:15 p.m., Mr. Alvin James, a member of our welding
team, accidentally suffered burn injuries inside the shop while the team was undertaking a
welding task.

Team member, Mr. Everald Jones had just begun welding a piece of metal, when Mr. James
walked by and accidentally kicked a piece of scrap that had fallen to the ground. Assuming that
it was cold, Mr. Jones picked it up and made to throw it in the scrap bin when it scorched him.
He was not wearing his safety gloves at the time.

Mrs. Stewart, the janitor, who was in the vicinity at the time, quickly fetched a basin of water
and placed his hand in. I also retrieved and applied some first aid ointment to the wound. Mr.
Jones and I took him to the Sick Bay, where Nurse Althea Thomas examined the wound and
asked me to rush him to the Spanish Town Hospital.

On our arrival at the hospital, Mr. James was taken to the Emergency Department where he was
treated and hospitalized in stable condition.He suffered severe burns to his fingers and hand.

A follow up appointment is scheduled next Thursday.

A compensation of BDT 10,000 is hereby recommended to provide Mr. James to cover the
medical expenses followed by an earned leave of 3 days to be granted.
 SAMPLE REPORT 2

Memorandum

Heading To: John Palmer, Managing Director

From: Florres Copler, Safety Engineer
Date: September 24, 2019

Subject: A report on the fire incident in the main factory

Opening With reference to the above, a detailed study has been made on the fire incident that took place
on the 23rd of this month in our main factory at Statefold.

On the above mentioned date, a huge fire had broken out around 11 a.m., in our Welding
Summary department. It spread so quickly that it consumed fairly a large number of tools and spare parts.
Above all, Mr. Sal, our chief welder, was also badly hurt. Luckily, he was the only person
working at that time as the other workers had gone for tea break.

Discussion
Immediately firemen were summoned and they extinguished the fire after battling for about half
an hour. Mr. Sal was hospitalized and he is now recovering fast.

Upon investigation, it is found that the fire broke out because of a short circuit in the main line.
Conclusion In addition, the wires had worn out and needed replacement. All these has resulted in the
devastating fire. The total loss is estimated to be nearly BDT 2,00,000.
To write an incident report, use a narrative format. Simply tell the story. Here’s an
incident report sample description of a slip or fall resulting in a fracture, written as a
narrative:

“On Friday afternoon, February 3, 2019, at 2 p.m. in ABC Shipping Co. located in
13th Avenue, Applewood, one of the warehouse workers (John Keegan) slipped
and fell while carrying heavy (85 lbs) inventory. The root cause is believed to be
the unavailability of a hand truck or pallet jack. Instead of waiting, John attempted
carrying the load himself. A second possible cause is the condition of John’s
PPE, specifically his boots, which are very worn in certain places.

When John fell, his colleagues rushed to his assistance. Suspecting a fracture,
the supervisor on the floor (Kathy Pickens) decided to call 911.
John said he felt a bit dizzy when he lost his balance and that he just ‘tripped
over his feet.’ He tried to minimize damage to the load itself while falling, which
may have led to a more awkward fall.

Two of his co-workers said that they noticed he was struggling a bit before the
fall, but were busy with their own tasks and felt it would be rude to ‘call him out.’
See the attached witness statements for more info.

John was taken to a nearby hospital and a fracture to his wrist was confirmed.
John will be out of work for a number of weeks.

The supervisor is currently working with the safety officer (Chris Darnell) to
assess the condition of the floor, the number and condition of hand trucks and
pallet jacks on the floor, as well as the condition of company-provided boots over
two years old.”

As you can see, including the full story, complete with small details and witness
statements will help you investigate and recall the incident with greater clarity.

After documenting the incident, you may have legal reporting requirements. Report and
store the files according to your regulator’s requirements. It’s generally best practice to
preserve the files for the duration of employment.