Incident Severity Classification Form
Use this form to report and classify incidents, assess their severity, and recommend appropriate actions.
Incident Title
*
Date and Time of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident
*
Type of Incident
*
Please Select
Safety
Security
Operational
Environmental
Health
Other
Please provide a detailed description of the incident
*
Who or what was affected by the incident?
*
Employees
Customers/Visitors
Equipment/Property
Environment
Operations/Services
Other
Severity Assessment
*
Rows
Minor
Moderate
Major
Critical
Injury/Health Impact
1
2
3
4
Property Damage
5
6
7
8
Service Disruption
9
10
11
12
Environmental Impact
13
14
15
16
Immediate Actions Taken
Recommended Follow-Up Actions
Severity Level (Evaluator's Rating)
*
Low
Medium
High
Critical
Name of Person Reporting
*
First Name
Last Name
Contact Email
*
example@example.com
Submit Classification
Should be Empty: