Checklist template

Incident report

A ready-to-use checklist with 77 items in 13 sections, covering Initial Incident Notification, Involved Person Profile, Witness Accounts & Evidence, Sequence of Events, Injury & Medical Triage, Property & Asset Damage and more. Use it as-is in Bindy, or adapt it to your own standards in minutes.

  • 13 Sections
  • 77 Items
  • 51 Yes / No checks
  • 8 Scored ratings
  • 860 Points

Use this template How audits work

1. Initial Incident Notification 7 items

  1. Date of Incident: Date
  2. Exact Time of Incident: Short text
  3. Specific Location/Area (e.g., Aisle 3, Kitchen Line, Loading Dock): Comments
  4. Name and Title of person completing this initial report: Comments
  5. Was the incident reported immediately upon occurrence? Yes / No 15 pts
  6. Was the scene immediately secured to prevent secondary incidents? Yes / No 20 pts
  7. Primary Incident Classification: Choice
    • Injury / Illness
    • Near-Miss (High potential for injury)
    • Property / Equipment Damage
    • Security / Behavioral Incident
    • Chemical / Environmental Spill
    • Vehicle / Asset Collision

2. Involved Person Profile 7 items

  1. Full Name of Involved Individual: Comments
  2. Employee ID / Job Title / Department: Comments
  3. Was the individual working their normally scheduled shift? Yes / No 5 pts
  4. Was the individual performing an assigned, standard job task? Yes / No 10 pts
  5. Has the individual completed standard onboarding safety training? Yes / No 15 pts
  6. Is the individual’s specialized task training/certification current? Yes / No 15 pts
  7. Affiliation / Status: Choice
    • Active Full-Time Staff
    • Active Part-Time / Seasonal Staff
    • Third-Party Vendor / Contractor
    • Guest / Customer / Visitor

3. Witness Accounts & Evidence 7 items

  1. Were direct witnesses present during the event? Yes / No 5 pts
  2. Full Name(s) and Contact Information of Witness(es): Comments
  3. Were written, signed witness statements obtained immediately? Yes / No 20 pts
  4. Is there CCTV / video surveillance footage capturing the incident? Yes / No 20 pts
  5. Has the video footage been exported, backed up, and archived? Yes / No 15 pts
  6. Were high-resolution photographs taken of the scene and equipment? Yes / No 15 pts
  7. Quality of Evidence Collected: Rating
    • Comprehensive (Video + Photos + Statements) 15 pts
    • Partial (Statements or Photos only) 7 pts
    • Minimal / Unverified 0 pts

4. Sequence of Events 7 items

  1. Detailed step-by-step description of actions leading up to the event: Comments
  2. Did the incident involve a slip, trip, or fall on the same level? Yes / No 10 pts
  3. Did the incident involve a fall from height (ladder/platform)? Yes / No 10 pts
  4. Was the individual struck by or crushed against an object? Yes / No 10 pts
  5. Was there a thermal burn, electrical shock, or extreme temp exposure? Yes / No 10 pts
  6. Did the task involve repetitive motion, twisting, or heavy lifting? Yes / No 10 pts
  7. Immediate Task Pace: Rating
    • Standard / Calm Workload 10 pts
    • Rushed / Peak Hour Overload 5 pts
    • Unauthorized Overtime / Fatigue 0 pts

5. Injury & Medical Triage 7 items

  1. Was First Aid required and administered on-site? Yes / No 10 pts
  2. Name and qualification of person administering First Aid: Comments
  3. Specific body part(s) injured (e.g., lower back, right index finger): Comments
  4. Did the individual explicitly refuse medical attention? Yes / No
  5. Was the individual transported to an Urgent Care or ER facility? Yes / No
  6. Were emergency medical services (911/Ambulance) dispatched? Yes / No
  7. Initial Work Capacity Outcome: Rating
    • Immediate Return to Normal Duties 20 pts
    • Placed on Modified / Light Duty 10 pts
    • Sent Home / Lost Work Time 0 pts

6. Property & Asset Damage 5 items

  1. Was company infrastructure, facility, or building property damaged? Yes / No 10 pts
  2. Was operational equipment, machinery, or a tool damaged/destroyed? Yes / No 10 pts
  3. Did the incident result in product loss, contamination, or spoilage? Yes / No 10 pts
  4. Description of damaged property/assets and affected SKUs: Comments
  5. Estimated Financial Impact: Choice
    • Minor (Under $500)
    • Moderate ($500 - $2,500)
    • Significant ($2,500 - $10,000)
    • Severe (Over $10,000 / Structural)

7. Environmental Telemetry 6 items

  1. Was lighting adequate and fully operational in the immediate area? Yes / No 10 pts
  2. Was the floor/walking surface completely clean, dry, and grease-free? Yes / No 20 pts
  3. Were aisles and walkways clear of pallets, boxes, or transit clutter? Yes / No 15 pts
  4. Were ambient noise levels within standard operational parameters? Yes / No 5 pts
  5. Was the facility temperature and ventilation operating normally? Yes / No 5 pts
  6. Housekeeping & Scene State: Rating
    • Excellent / Exceeds Standards 20 pts
    • Average / Minor Clutter Present 10 pts
    • Poor / Hazardous Conditions Observed 0 pts

8. Tools, Machinery & PPE 6 items

  1. Was all required Personal Protective Equipment (PPE) worn correctly? Yes / No 30 pts
  2. Was the PPE inspected and found to be in defect-free condition? Yes / No 15 pts
  3. Was the tool/machinery being used strictly for its designed purpose? Yes / No 20 pts
  4. Were all built-in machine guards and safety interlocks functional? Yes / No 25 pts
  5. Is the preventative maintenance log for the involved machinery current? Yes / No 15 pts
  6. Hardware Integrity Level: Rating
    • Flawless / Fully Maintained 20 pts
    • Operational but due for service 10 pts
    • Unsafe / Guarding Bypassed or Broken 0 pts

9. Deep-Root Cause Analysis 6 items

  1. Human Factor: Was a safety shortcut taken to speed up a task? Yes / No 20 pts
  2. Process Factor: Was the written SOP ambiguous, outdated, or absent? Yes / No 20 pts
  3. Training Factor: Was there a gap in specific hazard comprehension? Yes / No 20 pts
  4. Supervision Factor: Was direct oversight or leadership lacking? Yes / No 15 pts
  5. Equipment Factor: Did a component fail without prior warning? Yes / No 15 pts
  6. Primary Root Cause Driver: Choice
    • Behavioral Action / Decision Error
    • Equipment / Hardware Malfunction
    • Process / SOP Documentation Gap
    • Environmental / Unforeseen External Factor

10. Immediate Corrective Actions 5 items

  1. Was the immediate physical hazard repaired, removed, or locked out? Yes / No 30 pts
  2. Was the involved equipment tagged "Out of Service" pending review? Yes / No 20 pts
  3. Was a safety stand-down briefing conducted with the immediate shift? Yes / No 20 pts
  4. Detail all immediate corrective steps taken within the first 2 hours: Comments
  5. Triage Resolution Status: Rating
    • Hazard Fully Neutralized 25 pts
    • Temporary Controls Active 12 pts
    • Unresolved / Requires Outside Specialist 0 pts

11. Long-Term Prevention Plan 6 items

  1. Does the core Standard Operating Procedure (SOP) require a formal update? Yes / No 15 pts
  2. Is formal retraining scheduled for the entire department/location? Yes / No 20 pts
  3. Are additional safety signs, floor markings, or visual aids ordered? Yes / No 15 pts
  4. Will maintenance frequency on this equipment class be increased? Yes / No 15 pts
  5. Describe the documented 30-day permanent solution and assigned owner: Comments
  6. Prevention Plan Implementation: Rating
    • Action Items Assigned with Deadlines 20 pts
    • Strategy Drafted but Pending Approval 10 pts
    • No Long-Term Plan Developed 0 pts

12. Internal Escalation & Sign-off 4 items

  1. Has the Location Manager reviewed and signed off on this report? Yes / No 20 pts
  2. Has the internal Health & Safety Committee / HR team been notified? Yes / No 20 pts
  3. Were all corrective actions logged into the master operations tracker? Yes / No 20 pts
  4. Final Management Comments and Closed-Loop Sign-off Date: Comments

13. External & Legal Compliance 4 items

  1. Does this incident meet the threshold for regulatory reporting (e.g., OSHA)? Yes / No
  2. Has the Workers' Compensation insurance carrier been formally notified? Yes / No
  3. Is the incident securely archived in accordance with privacy compliance? Yes / No 20 pts
  4. Overall Compliance Confidence: Rating
    • Complete Protocol Followed 20 pts
    • Minor Administrative Follow-up Needed 10 pts
    • Critical Reporting Deadline Missed 0 pts

About this template

This checklist is part of the Bindy template library. Yes / No checks score 1 point when met; ratings score the points shown for each option. The overall score is the percentage of points earned, with N/A answers excluded. In Bindy you can add photos, assign corrective actions, require sign-off and compare results across sites.

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