Severity Assessment Form
Please provide detailed information to assess the severity of the reported incident or situation.
Your Full Name
*
First Name
Last Name
Your Email Address
*
example@example.com
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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
Equipment Failure
Environmental
Other
Please describe the incident or situation in detail
*
Severity Assessment Matrix
*
Rows
None
Minor
Moderate
Severe
Critical
Impact on People
1
2
3
4
5
Impact on Operations
6
7
8
9
10
Impact on Environment
11
12
13
14
15
Financial Impact
16
17
18
19
20
How urgent is the response required?
*
Immediate (within 1 hour)
High (within 4 hours)
Moderate (within 24 hours)
Low (monitor only)
Rate the overall severity of this incident
*
1
2
3
4
5
Who or what was affected? (Select all that apply)
*
Employees
Customers/Visitors
Equipment
Property/Facility
Environment
Other
Please list any immediate actions taken or recommendations for follow-up
Submit Assessment
Should be Empty: