Incident report sample
- Report to OSHA within, hours (0 = no phone report due)
- 0
- Recordable on the OSHA 300 log (1 = yes)
- 1
- Lost work hours
- 24
Every figure on this page is computed from the inputs you enter, by the method stated below it. The only constants DailyLogDesk supplies are the published reporting clocks and assessment steps, each cited where it is used. The defaults are a worked example to replace with your own.
An incident report sample for a small contractor, filled the way an investigator or an insurer will read it: what happened, where and when, who was involved and who saw it, what the injury or damage was, what treatment was given, what equipment and what method were in use, the immediate cause and the underlying one, and the decision on whether the incident is recordable or reportable. The incident report template on this site produces the report from your facts and answers the recordability question against the published rule, free and without an account; Pro keeps it against the project.
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The facts, in the order they happened
The sample opens with the fixed facts: date, time, exact location on the site, the injured person and their employer, the witnesses, the task in progress and the RAMS or method in force for it. Then the sequence: what the person was doing, what happened, what happened next. Written that day, in plain words, with no conclusion drawn in the narrative; the conclusion has its own block later.
Injury, treatment and the recordability decision
The injury by body part and nature, the first aid or medical treatment given and by whom, the hospital if any, and the days away or on restricted duty as they accrue. That block is what decides recordability: the template on this site reads the treatment and the outcome against the 29 CFR 1904.7 criteria and the 1904.39 reporting clocks, so the decision on the form is the rule's decision and not a guess.
Cause, corrective action and the RAMS change
The immediate cause, the underlying cause, and the corrective action with a name and a date against it. The block that most samples leave blank and that an investigator reads first. Where the cause was a control that was missing or was not followed, the risk assessment is revised and the revision is briefed, and Pro links the incident to the assessment it changed.
Who sees it and where it lives
The report goes to the employer, the principal contractor where there is one, the insurer where the policy requires notice, and OSHA where 1904.39 requires it. Pro keeps the report against the project with the photographs, the witness statements and the corrective action, and exports the log when it is asked for.
Will it do what you need for Incident report sample?
Tell us what your business needs and we will tell you straight whether DailyLogDesk Pro does it today, whether it is coming, or whether you are better off with something else. A person reads these and replies.
Incident report sample: common questions
Is the incident report template free?
Yes. The incident report template on this site builds the report and answers the recordability question with no account and no card; Pro keeps the reports and the log against the project.
What is the difference between recordable and reportable?
Reportable means OSHA must be told within the 1904.39 clocks: a fatality, an in-patient hospitalization, an amputation or the loss of an eye. Recordable means the injury goes on the log under 1904.7, which includes medical treatment beyond first aid among its criteria.
Should a near miss get a report?
Yes, on the same form with no injury block filled. A near miss is the incident that has not happened yet, and the corrective action is the same.