Rope Access Safety Incident Report Form
Use this form to report a rope access safety incident, record what happened, and capture the immediate response and equipment involved.
Incident Details
Date of Incident
*
-
Month
-
Day
Year
Date
Time of Incident
*
Hour Minutes
AM
PM
AM/PM Option
Site / Location
*
Incident Summary
People and Rope Access Situation
Reporter Name
*
First Name
Middle Name
Last Name
Reporter Role / Job Title
*
Type of Rope Access Task
*
Please Select
Inspection
Maintenance
Repair
Cleaning
Installation
Rescue Drill
Other
Number of People Involved
*
Incident Outcome and Immediate Response
Incident outcome
*
No injury or damage
Near miss
First aid only
Medical treatment required
Lost time injury
Equipment damage
Property damage
Environmental release
Other
Immediate actions taken
*
Emergency services or medical help contacted?
*
No
Yes, emergency services
Yes, medical help
Yes, both
Other
Equipment involved or damaged
Submit Incident Report
Should be Empty: