Incident Report Templates (19)

Updated June 01, 2022

An incident report details an event involving an accident, injury, or other unusual activity. The report should include the person affected, a description of the incident, and any involved parties or witnesses.

An incident report should be completed as soon as possible after the event to get the most accurate testimony from those involved.

By Type (19)

How to Write

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I. Report Introduction

(1) Report Date. Before submitting information to this document, locate the (formatted) lines labeled “Date Of Report” in the introduction. Here, the date when this report is completed should be supplied as a matter of record.

II. Person Involved

(2) Full Name. The first section of this report, “Person Involved,” seeks the full name of the individual who wishes to make an official statement regarding the concerned incident utilizing this document. To this end, the legal name of this report’s Filer should be dispensed to the line labeled “Full Name.”

(3) Filer Address. In addition to the legal name of the Person Involved (or Filer), his or her residential address is required by the First Section on the adjacent “Address” line. Since this address will be used to support the Filer’s identity, it must be the physical address of the home where he or she can be visited and should be presented as it is displayed on his or her government-issued I.D. (i.e. Driver’s License/State ID).

(4) Driver’s License No. This report will require that the Filer be positively identified. Therefore, the area labeled “Identification” in Section 1 shall request that the ID used to verify the identity of the Filer must be documented. In many cases, the Filer’s Driver’s License or State-Issued ID may be used (and possibly inspected by an Interviewer) for this purpose. If so, the first option in Section 1, “Driver’s License No” should be selected with a mark to its corresponding checkbox. Additionally, the ID Number issued to the Filer on his or her Driver’s License or State-Issued ID must be presented on the space provided.

(5) Passport No. If the Filer does not have a Driver’s License or State I.D. or prefers to verify his or her identity with a federal passport, then the second checkbox should be selected from the “Identification” section and the Filer’s passport number should be documented on the space following the words “Passport No.”

(6) Other. In some cases, the Filer may be allowed and/or need to use another form of ID. Provided this is acceptable to the Entity seeking the Filer’s statement through this report, the third checkbox would need to be chosen from the “Identification” section. After this selection is made, the details used to identify the Entity that has issued the ID, as well as the Filer, should be presented. For instance, if this paperwork is being submitted by a Student making a statement regarding an incident that happened at his or her school, then the Student ID card issued to him or her by the School may be both a sufficient source of ID and contain the information necessary to identify the Student to the School (i.e. the Filer’s Student ID Number).

(7) Phone. The telephone number where the Filer may be contacted to discuss the incident further should be produced on the line holding the “Phone” label. Notice that it has been formatted to accept a standard phone number (i.e. area code + phone number). Complete this area with the cell phone (recommended), home phone, or work number where the Filer can be easily reached.

(8) E-Mail. The electronic mail address or “E-Mail” address where the Filer can be reached should be submitted to complete this area.

II. The Incident

(9) Date Of Incident. The “Incident” section will present several areas that will enable the Filer to deliver some vital information regarding the incident itself. Begin this section by recording the calendar date (when the incident being reported occurred) on the appropriately formatted spaces labeled “Date Of Incident.”

(10) Time Of Incident. Continue defining when the incident happened by presenting the time of its occurrence across the two lines labeled “Time.” This should be documented in a standard 12-hour format.

Select One Checkbox From Item 11

(11) Time Of Day. Naturally, there should be no question left as to what part of the day when the incident occurred. If the incident occurred between Midnight and Noon then select the “AM” checkbox. Otherwise, if the incident occurred between Noon and Midnight, select the “PM” box.

(12) Location Of Incident. The physical location where the incident happened must be specifically defined. Define the location by supplying the physical address where the incident occurred. Generally this will require the building number, street, floor or unit number, city, and the zip code of the physical location of the incident submitted to the space available. If needed, a physical description of the incident’s location on a large property may be documented with the address. For instance, indicating where on a factory floor an accident occurred as well as the physical address of the factory would be recommended.

(13) Description. The discussion defining the incident must continue with a detailed description of the event that prompted this report. This should be as impartial as possible and remain close to the facts. It should be noted that, in many cases, even minor details that may seem unimportant should be documented. A couple of lines have been provided but, if needed, an attachment continuing the Filer’s report can be affixed to this paperwork so long as this is done before the testimonial signature is provided.

III. Injuries

Select Item 14 And Complete Item 16 Or Select Item 15

(14) Injury Status. The Third Section, titled “Injuries,” gives the Filer the opportunity to establish whether or not anyone was injured by or during the incident. If the incident caused physical injury then a report regarding the injury must be dispensed to this document. If the Filer (or anyone involved with the incident) suffered an injury related to the incident, then select the checkbox labeled “Yes” from the “Injuries” section.

(15) No Injury. If no one was injured as a result of this incident, then select the “No” checkbox. This will solidify that as far as the Filer of this report knows, no one was injured as a direct result of this incident.

(16) Description. Fully describe any injuries that were caused by the incident or were suffered during the incident (in its immediate vicinity) on the blank spaces following the phrase “If Yes, Describe The Injuries.” Such a record should contain a physical description of what was visible at the time of the incident or shortly after, what the injury was, and the name (if available) of the Party who suffered physical injuries during or as a result of the incident. The Filer should not attempt to diagnose any injuries suffered. Thus, this must be a physical description of trauma suffered to one or more body parts regardless of the level of trauma.

III. Witnesses

Select Item 17 And Complete Item 19 Or Select Item 18

(17) Witness(es) Present. If there were any Witnesses (other than the Filer) to the incident who were present for any part of the incident so that he or she were able to visually observe, hear, or detect an odor from the incident then, select the “Yes” checkbox from the area titled “Witnesses.”

(18) No Witnesses Present. If there were no other Parties aware of the incident while it occurred, then select the checkbox “No.”

(19) Witness Identity(ies). If the “Yes” box was selected and there were Witnesses to the incident, then record the full name of each Party who was both in proximity and aware of the incident. Since Reviewers of this report may require further testimony from the Witnesses to the incident, a record of the mailing address, contact telephone number, and email address for each Witness must be presented with each one’s identity.

IV. Police/Medical Services

Select Item 20 Or Select Item 21

(20) Police Notified. Depending upon the nature of the incident, the authorities may have been alerted. The section titled “Police/Medical Services” will handle this topic and allow the Filer to present the facts of any formal response from the Authorities. If the Police were notified of the incident by anyone, then select the first checkbox after the question “Police Notified.”

(21) Police Were Not Notified. Mark the checkbox labeled “No” if no one notified the Police of the incident.

Select Item 22 Or Select Item 23 To Complete Item 20

(22) Police Report Filed. If the Police were notified and responded, then a Police Report should have been generated and filed. If this was the case, then place a mark in the “Yes” checkbox to answer the question “If Yes, Was A Report Filed.”

(23) No Police Report Filed. If a Police Report was not filed (even if the Police were notified) then indicate this by selecting the “No” checkbox from the section titled “Police/Medical Services.”

Select Item 24 Or Select Item 25 Or Select Item 26

(24) Medical Treatment Provided. If medical treatment was administered to the Filer during the incident or immediately following the incident, then select the first checkbox on display following the question “…Medical Treatment Provided.”

(25) No Medical Treatment Provided. If no medical treatment was administered as a result of the incident then select the “No” checkbox.

(26) Refused Medical Treatment. If the incident resulted in the Filer being asked if he or she would like medical treatment that he or she refused (at the time or immediately after) then select the “Refused” checkbox.

Select Item 27 Or Select Item 28 Or Select Item 29

(27) On-Site Medical Treatment. If medical treatment was offered at the address where the incident occurred by responding Medical Personnel (i.e. EMT/Ambulance) and accepted by the Filer then the “On Sites” checkbox should be selected.

(28) Hospital Visit. If medical treatment was offered and accepted by the Filer as a result of this incident and a trip to the hospital was required, then place a mark in the checkbox labeled “Hospital.”

(29) Other Medical Treatment. If medical treatment was administered but not on-site or at a Hospital then select the final checkbox presented. Use the space after the word “Other” to describe the medical treatment administered to the Filer, where it was administered, and to identify the Treatment Provider by name (whether Entity or Private Party).

V. Person Filing Report

(30) Signature. The Filer must sign his or her name to show that the above report regarding the incident is as accurate as possible.

(31) Date. The date when the Filer signs this paperwork must be presented where requested.

Office Use Only

(33) Record Keeping. The final area of this paperwork, titled “Office Use Only,” has been reserved for the Entity receiving this report. Here the Reviewer may document the date when the report was received as well as any action that was taken as a response to the receipt of this report.