Lost Time Incident Rate Calculation Form
Report incidents and calculate the LTIR for your workplace safety records.
Organization / Site Name
*
Department / Location
*
Reporting Period (e.g., Q1 2026, March 2026)
*
Incident Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Incident
*
Please Select
Injury
Illness
Fatality
Near Miss
Other
Incident Description
*
Number of Lost Workdays
*
Number of Lost Time Incidents
*
Total Hours Worked in the Reporting Period
*
Corrective Actions Taken
Person Reporting (Full Name)
*
First Name
Last Name
Contact Email
example@example.com
Submit Report
Should be Empty: