Incident Report Insights Survey
Share your experience and insights regarding a recent incident to help us improve safety and response processes.
What type of incident are you reporting feedback on?
*
Please Select
Workplace Accident
Near Miss
Property Damage
Security Breach
Environmental Incident
Other
Date of the incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location of the incident
*
Please provide a brief description of the incident
*
How would you rate the severity of the incident?
*
Minor
1
2
3
4
Severe
5
1 is Minor, 5 is Severe
Who was affected by the incident? (Select all that apply)
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Employee(s)
Visitor(s)
Contractor(s)
Property/Equipment
Environment
Other
Please indicate the main contributing factors to the incident (select up to 3)
*
Human Error
Equipment Failure
Lack of Training
Procedural Issues
Environmental Conditions
Communication Breakdown
Other
How effective was the immediate response to the incident?
*
1
2
3
4
5
Please indicate your level of agreement with the following statements about the incident handling.
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
The incident was reported promptly.
1
2
3
4
5
Communication about the incident was clear.
6
7
8
9
10
Corrective actions were implemented quickly.
11
12
13
14
15
Support was provided to those affected.
16
17
18
19
20
What could be improved to prevent similar incidents in the future?
Overall, how satisfied are you with the way the incident was handled?
*
1
2
3
4
5
If you would like to be contacted for follow-up, please provide your email address (optional)
example@example.com
Submit Insights
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