Incident Report

INCIDENT REPORT, CONFIDENTIAL AND PRIVILEGED. This report is prepared at the direction of [Company Legal Department / Human Resources / Risk Management] and may be protected by the attorney-client privilege and/or work product doctrine. Date of Incident: [____________]. Time of Incident: [____________] [a.m./p.m.]. Date of Report: [____________]. Location of Incident: [____________] (department / floor / specific area). Type of Incident: [workplace injury / property damage / security breach / alleged harassment or discrimination / near-miss / vehicle accident / other]. Report Prepared by: [Name, Title]. This report is prepared for the purpose of investigating the incident described herein and for compliance with applicable federal and state workplace safety and reporting requirements, including OSHA 29 C.F.R. Part 1904 where applicable.

Narrative Description of Incident: [Provide a detailed, chronological account of the events leading up to, during, and immediately following the incident, using objective language and avoiding opinion, speculation, or legal conclusions. Include: (a) what task(s) were being performed at the time of the incident; (b) the sequence of events leading to the incident; (c) the specific nature of the injurious or harmful event; (d) the immediate response taken; and (e) any equipment, machinery, substances, or conditions involved]. The narrative above reflects the information available to the preparer as of the date of this report; the Company reserves the right to supplement or amend this report upon receipt of additional information.

INJURED / AFFECTED PARTY: Name: [____________]. Job Title: [____________]. Department: [____________]. Employment Status: [full-time / part-time / contractor / visitor / other]. Date of Hire: [____________]. Shift/Schedule at Time of Incident: [____________]. Supervisor: [____________]. Length of Time in Current Position: [____________]. Prior incidents or injuries on file: [Yes / No]. The affected party [was / was not] performing assigned job duties at the time of the incident. [If not, describe the activity being performed.] The affected party has provided a written statement attached hereto as Exhibit A.

WITNESSES: The following individuals witnessed the incident or have relevant information: (1) [Name], [Title/Relationship], [Contact Info], [brief description of what this witness observed]; (2) [Name], [Title/Relationship], [Contact Info], [brief description]; (3) [Name], [Title/Relationship], [Contact Info], [brief description]. Written statements have been obtained from [list witnesses who provided statements] and are attached hereto. The following individuals were identified as potential witnesses but [declined to provide a statement / were unavailable / had limited information]: [list, if any]. All witness interviews were conducted by [Name, Title] on [____________].

INJURIES SUSTAINED: [Injured party] sustained the following injuries as a result of the incident: [describe injury/injuries with specificity, e.g., laceration to left forearm approximately 3 cm in length / contusion to right knee / strain to lower back / loss of consciousness for approximately [____] minutes]. First aid was administered on-site by [Name, Title] at [time]. The injured party [was / was not] transported to [hospital / urgent care / physician's office] for further treatment. Medical release to work: [full duty / restricted duty, describe restrictions / not yet determined]. Workers' compensation claim has been [filed / not yet filed, pending]. OSHA recordable: [Yes / No / Under evaluation].

PROPERTY / EQUIPMENT DAMAGE: [Describe any property or equipment damage resulting from the incident, including: (a) item(s) damaged; (b) description and estimated value of damage; (c) whether the property is owned by the Company, an employee, or a third party; (d) whether the property is repairable or must be replaced; and (e) any impact of the damage on operations.] Estimated cost of property damage: $[____________]. [If no property damage: No property or equipment damage resulted from this incident.] Photographs of the incident scene and damaged property have been taken and are preserved in [location / attached as Exhibit B].

ROOT CAUSE ANALYSIS: The immediate cause of the incident was [describe, e.g., failure to use required personal protective equipment / wet floor without warning sign / equipment malfunction]. The contributing causes include: (a) [contributing cause 1]; (b) [contributing cause 2]; and (c) [contributing cause 3]. The root cause(s) of the incident, as determined by investigation, are: [describe systemic or programmatic root cause(s), e.g., inadequate safety training / failure to enforce existing safety protocols / inadequate equipment maintenance / unclear work procedures]. This analysis is prepared for purposes of corrective action and process improvement.

CORRECTIVE AND PREVENTIVE ACTIONS: The following corrective actions have been implemented or are scheduled: (a) [Action 1: describe specific corrective action, responsible party, and completion date]; (b) [Action 2: describe specific corrective action, responsible party, and completion date]; (c) [Action 3: describe specific corrective action, responsible party, and completion date]. Follow-up to verify implementation and effectiveness of corrective actions will be conducted by [Name, Title] on or before [____________]. This incident and the corrective actions taken will be reviewed at the next [safety committee meeting / department meeting] on [____________]. A copy of this report has been [provided to / will be provided to] the affected employee upon request, in accordance with applicable law. Report reviewed by: [Supervisor Signature] [HR Representative Signature] [Safety Officer Signature].