Incident/Improvement Report
Date*
Day Month Year
Reported by*
First Name Last Name
Client/Customer*
Location*
Type of Issue*
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Description*
Actions Taken*
Cause/Recommendations*
Accident/Injury Details
Was there an injury sustained*
Injured person 1
First Name Last Name
Person 1: Position
Details of injury; Person 1
Person 1: Length of employment
Person 1: Age
Injured person 2
First Name Last Name
Details of injury; Person 2
Person 2: Position
Person 2: Length of employment
Person 2 : Age
Actions taken at the scene
None necessary Observation First Aid Called ambulance
Describe any property damage
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Witness 1
First Name Last Name
Witness 1 Phone
Area Code Phone Number
Witness 1 address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code Country
Witness 2
First Name Last Name
Witness 2 phone
Area Code Phone Number
Witness 2 address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code Country
OFFICE USE ONLY
Management Review
Further Action
Corrective/Preventative Actions
Person responsible
First Name Last Name
Deadline
Month Day Year
Results of action
Was the issue resolved?
Date resolved
Month Day Year
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Incident/Improvement Report

Accident/Injury Details