Incident report form
Use this form to record a workplace incident properly: what happened, who was involved, the injury and treatment, whether it must be REPORTED to OSHA (a fatality within 8 hours; an in-patient hospitalization, amputation, or loss of an eye within 24 hours), whether it is RECORDABLE on your OSHA 300 log, and the corrective actions so it does not happen again.
Incident report form
Company: ____________
Jobsite: ____________
Date: ____________
Incident details
| Date and time of incident: ____________ | N/A · Action | |
| Exact location on the jobsite: ____________ | N/A · Action | |
| Project / GC: ____________ | N/A · Action | |
| Task being performed at the time: ____________ | N/A · Action | |
| Equipment, tools, or materials involved: ____________ | N/A · Action |
People
| Injured or involved employee(s), employer and trade: ____________ | N/A · Action | |
| Supervisor notified (name, time): ____________ | N/A · Action | |
| First aid responder: ____________ | N/A · Action |
What happened
| Describe the sequence of events (attach a page if needed) | N/A · Action | |
| PPE being worn at the time | N/A · Action | |
| Site or weather conditions relevant to the incident | N/A · Action |
Injury and treatment
| Nature of injury and body part (if any) | N/A · Action | |
| First aid given on site | N/A · Action | |
| Medical treatment beyond first aid (doctor, clinic, ER) | N/A · Action | |
| Days away from work, restricted duty, or job transfer expected | N/A · Action |
Report to OSHA? (tick and act)
| Work-related FATALITY: report to OSHA within 8 HOURS | N/A · Action | |
| In-patient HOSPITALIZATION, AMPUTATION, or LOSS OF AN EYE: report within 24 HOURS | N/A · Action | |
| How to report: nearest OSHA office, 1-800-321-6742, or osha.gov/report (applies even to employers exempt from routine recordkeeping) | N/A · Action |
Recordable on the OSHA 300 log?
| Death, days away from work, restricted work or job transfer, medical treatment beyond first aid, or loss of consciousness makes the case recordable | N/A · Action | |
| If recordable: enter it on the OSHA 300 log within 7 calendar days | N/A · Action | |
| Case number assigned: ____________ | N/A · Action |
Witnesses and evidence
| Witness names and contact details: ____________ | N/A · Action | |
| Photos taken of the scene | N/A · Action | |
| Statements collected | N/A · Action |
Causes and corrective actions
| Immediate cause: ____________ | N/A · Action | |
| Contributing factors (training, controls, conditions): ____________ | N/A · Action | |
| Corrective actions, owner, and due date: ____________ | N/A · Action | |
| JHA / safety plan for this task reviewed and updated | N/A · Action |
Completed by: ____________________
Signature: ____________________
tailgatedocs.com · Free printable form. Not legal advice; adapt to your jobsite.
Common questions
▸Which incidents must be reported directly to OSHA?
A work-related fatality within 8 hours, and an in-patient hospitalization, amputation, or loss of an eye within 24 hours. Report to the nearest OSHA office, the 24-hour line 1-800-321-6742, or online. This applies even to employers exempt from routine recordkeeping.
▸What is the difference between reportable and recordable?
Reportable means you must contact OSHA directly on the 8-hour or 24-hour clock. Recordable means the case goes on your OSHA 300 log within 7 calendar days: death, days away, restricted duty or transfer, medical treatment beyond first aid, or loss of consciousness.
▸How long do injury records have to be kept?
OSHA requires injury and illness records to be retained for five years following the year they cover. Keep incident reports with them; they are the backup behind every log entry.
An incident means the JHA or safety plan for that task did not hold. Regenerate it in minutes before the crew goes back.
Forms record what happened on the job; the JHA, safety plan, or written program is what a GC, prequal portal, or inspector asks to see. Generate a verified, job-specific one in minutes.