Confidential — For Internal Use Only. All Workplace Incidents Must Be Reported Immediately. This Form Must Be Completed Within 24 Hours Of The Incident.
Section 1: Establishment Information
Field | Details |
Restaurant Name | |
Location / Address | |
Country | |
Branch / Unit | |
Manager On Duty | |
Report Prepared By | |
Date Of Report (Dd/Mm/Yyyy) | |
Time Of Report | ☐ Am ☐ Pm |
Section 2: Employee Information
Field | Details |
Full Legal Name | |
Position / Job Title | |
Employee Id | |
Date Of Hire (Dd/Mm/Yyyy) | |
Years In Current Role | |
Shift Schedule | ☐ Full-Time ☐ Part-Time ☐ Temporary ☐ Casual |
Primary Phone | |
Emergency Contact (Name & Phone) | |
Direct Supervisor |
Department: ☐ Kitchen ☐ Front Of House ☐ Bar / Beverage ☐ Maintenance ☐ Cleaning ☐ Management ☐ Other: _______________
Section 3: Incident Information
Field | Details |
Date Of Incident (Dd/Mm/Yyyy) | |
Time Of Incident | ☐ Am ☐ Pm |
Shift | ☐ Opening ☐ Mid-Day ☐ Closing ☐ Overnight |
Specific Location Of Incident | |
Weather Conditions (If Relevant) | ☐ Clear ☐ Rainy ☐ Icy ☐ Humid ☐ Other: ___________ |
Witnesses Present
# | Full Name | Position | Contact Number |
1 | |||
2 | |||
3 |
☐ Additional Witnesses — Attach a Separate Sheet
Section 4: Incident Classification
Primary Incident Type (Select One)
Type | |
☐ | Slip, Trip, Or Fall |
☐ | Burns Or Scalds |
☐ | Cuts Or Lacerations |
☐ | Chemical Exposure Or Contact |
☐ | Struck By / Against Object |
☐ | Lifting Or Strain Injury |
☐ | Equipment-Related Injury |
☐ | Electrical Incident |
☐ | Violence Or Assault |
☐ | Food Poisoning / Illness |
☐ | Other: |
Contributing Factors (Select All That Apply)
Factor | Factor | ||
☐ | Wet Or Slippery Surfaces | ☐ | Poor Lighting |
☐ | Equipment Malfunction | ☐ | Inadequate Training |
☐ | Time Pressure / Rushing | ☐ | Fatigue |
☐ | Improper Procedures | ☐ | Missing Safety Equipment |
☐ | Language / Communication Barrier | ☐ | Other: ___________ |
Section 5: Detailed Incident Description
What Was The Employee Doing When The Incident Occurred?
Describe Exactly How The Incident Happened:
Equipment, Tools, Or Materials Involved:
Sequence Of Events Leading To The Incident:
Step | Description |
1 | |
2 | |
3 | |
4 |
Section 6: Injury Assessment
Nature Of Injury (Select All That Apply)
Injury | Injury | ||
☐ | Laceration / Cut | ☐ | Burn |
☐ | Bruise / Contusion | ☐ | Sprain / Strain |
☐ | Fracture | ☐ | Puncture |
☐ | Chemical Burn | ☐ | Electrical Shock |
☐ | Concussion | ☐ | Other: ___________ |
Body Part(S) Affected (Select All That Apply)
Body Part | Body Part | ||
☐ | Head / Face | ☐ | Eyes |
☐ | Neck | ☐ | Back |
☐ | Arms | ☐ | Hands / Fingers |
☐ | Chest | ☐ | Abdomen |
☐ | Legs | ☐ | Feet / Toes |
☐ | Multiple Areas |
Specific Location On Body: _______________________________________________
Initial Symptoms (Select All That Apply)
Symptom | Symptom | ||
☐ | Pain | ☐ | Swelling |
☐ | Bleeding | ☐ | Loss Of Consciousness |
☐ | Numbness | ☐ | Dizziness |
☐ | Nausea | ☐ | Bruising |
☐ | Limited Mobility | ☐ | Other: ___________ |
Employee's Description Of Pain / Discomfort:
Section 7: Medical Response
Field | Details |
First Aid Administered? | ☐ Yes ☐ No |
First Aid Provider | |
First Aid Certification Level | ☐ Basic ☐ Cpr/Aed ☐ Professional ☐ Other: _______ |
Medical Treatment Required | ☐ None ☐ Otc Medication ☐ Clinic / Urgent Care ☐ Hospital Er ☐ Ambulance ☐ Hospital Admission ☐ Specialist Referral ☐ Employee Refused |
Medical Facility (If Applicable) | |
Treating Physician | |
Expected Recovery Time | ☐ Same Day ☐ 1–3 Days ☐ 1–2 Weeks ☐ Over 2 Weeks ☐ Unknown |
First Aid Actions Taken:
Section 8: Documentation & Evidence
Evidence Type | Available? | Reference / Notes |
Photographs | ☐ Yes ☐ No | |
Incident Scene Diagram | ☐ Yes ☐ No | |
Security Camera Footage | ☐ Yes ☐ No | Camera Location / Timestamp: |
Equipment Maintenance Records | ☐ Yes ☐ No | |
Training Records | ☐ Yes ☐ No | |
Safety Inspection Reports | ☐ Yes ☐ No | |
Previous Incident Reports | ☐ Yes ☐ No | |
Other | ☐ Yes ☐ No |
Section 9: Equipment & Environmental Analysis
Equipment Involved
Field | Details |
Equipment Type | |
Make / Model / Serial Number | |
Last Maintenance Date (Dd/Mm/Yyyy) | |
Equipment Condition | ☐ Good ☐ Fair ☐ Poor ☐ Unknown |
Operating Properly At Time Of Incident? | ☐ Yes ☐ No ☐ Unknown |
Removed From Service? | ☐ Yes ☐ No ☐ N/A |
Environmental Conditions At Time Of Incident
Condition | Status |
Lighting | ☐ Adequate ☐ Poor ☐ Excessive Glare |
Floor Condition | ☐ Dry ☐ Wet ☐ Greasy ☐ Debris Present |
Temperature | ☐ Normal ☐ Hot ☐ Cold ☐ Extreme |
Noise Level | ☐ Normal ☐ Excessive ☐ Distracting |
Ventilation | ☐ Adequate ☐ Poor ☐ Fumes Present |
Personal Protective Equipment (PPE)
Field | Response |
PPE Required For Task? | ☐ Yes ☐ No |
PPE Available To Employee? | ☐ Yes ☐ No |
PPE Being Used At Time Of Incident? | ☐ Yes ☐ No |
PPE Used Correctly? | ☐ Yes ☐ No |
Ppe Type | |
Ppe Condition | ☐ Good ☐ Damaged ☐ Inadequate |
Section 10: Investigation & Root Cause Analysis
Immediate Actions Taken After Incident:
Root Cause (Select Primary Cause)
Cause | |
☐ | Human Error / Procedural Violation |
☐ | Equipment Failure / Malfunction |
☐ | Environmental Hazard |
☐ | Inadequate Training |
☐ | Insufficient Supervision |
☐ | Poor Workplace Design |
☐ | Time / Production Pressure |
☐ | Communication Breakdown |
☐ | Language Barrier |
☐ | Other: ___________ |
Contributing Factors (Detailed):
Could This Incident Have Been Prevented? ☐ Yes ☐ No
If Yes, Explain How: _______________________________________________
Section 11: Corrective & Preventive Actions
Immediate Corrective Actions Implemented (Select All That Apply)
Action | Action | ||
☐ | Area Secured / Cleaned | ☐ | Equipment Repaired / Replaced |
☐ | Staff Briefing Conducted | ☐ | Additional Signage Posted |
☐ | Procedure Modified | ☐ | Other: ___________ |
Long-Term Preventive Measures Planned (Select All That Apply)
Measure | Measure | ||
☐ | Employee Retraining Program | ☐ | Equipment Upgrade / Replacement |
☐ | Policy Revision | ☐ | Environmental Modification |
☐ | Increased Supervision | ☐ | Safety Audit Scheduled |
☐ | Multilingual Safety Materials | ☐ | Other: ___________ |
Field | Details |
Person Responsible For Follow-Up | |
Target Completion Date (Dd/Mm/Yyyy) | |
Follow-Up Review Scheduled? | ☐ Yes — Date: ___________ ☐ No |
Section 12: Employee Statement
Employee's Account Of The Incident (In Employee's Own Words):
I Confirm That The Information Provided Above Is Accurate And Complete To The Best Of My Knowledge.
Employee Signature | Date (Dd/Mm/Yyyy) |
Section 13: Management Review
Field | Details |
Investigated By | |
Investigation Date (Dd/Mm/Yyyy) |
Manager Comments:
Role | Signature | Date (Dd/Mm/Yyyy) |
Supervisor | ||
General Manager |
Section 14: Administrative Processing
Report Filed With (Select All That Apply)
Department / Body | |
☐ | Human Resources |
☐ | Insurance Provider — Carrier: ___________ |
☐ | Workers' Compensation / Workmen's Compensation |
☐ | Relevant Health & Safety Authority (E.G. Osha / HSE / Local Equivalent) |
☐ | Legal Department |
☐ | Health & Safety Committee |
☐ | Corporate Risk Management |
☐ | Other: ___________ |
Field | Details |
Incident Report Reference Number | |
Workers' Compensation Claim Number | |
Insurance Claim Number | |
Recordable Incident (Per Local Regulation)? | ☐ Yes ☐ No |
Days Away From Work | |
Restricted / Light Duties Available? | ☐ Yes ☐ No |
Expected Return To Work Date (Dd/Mm/Yyyy) |
Follow-Up Actions Required (Select All That Apply)
Action | Assigned To | Due Date | |
☐ | Medical Follow-Up | ||
☐ | Equipment Inspection | ||
☐ | Safety Training Update | ||
☐ | Policy Review | ||
☐ | Incident Trend Analysis | ||
☐ | Other: ___________ |
Section 15: Final Approvals
Role | Name | Signature | Date (Dd/Mm/Yyyy) |
Hr Representative | |||
Safety Officer | |||
Risk Manager |
Confidentiality Notice
This Incident Report Contains Confidential Information Prepared For Internal Use, Insurance Claims Processing, Legal Compliance, And Workplace Safety Improvement. Distribution Is Restricted To Authorised Personnel Only. This Document Must Be Stored Securely In Accordance With Company Policy And Applicable Privacy And Data Protection Laws.
Form Version: 3.0 | Date Format: Dd/Mm/Yyyy Throughout For Enquiries: Contact Your Human Resources Department Or Safety Officer.