--- generated_by: surveylegend-page-markdown title: Incident Report Form Template | SurveyLegend description: Record a workplace incident's time, location, observed facts, and immediate actions. Customize seven practical incident report fields in SurveyLegend. canonical: https://www.surveylegend.com/survey-examples-templates/web-forms-questionnaires/incident-report-form-template/ --- # Incident Report Form Template An incident report form records what happened, where and when it occurred, and what actions were already taken. Use these seven optional example fields to prepare a factual account for the appropriate reviewer. [Try this template ](https://app.surveylegend.com/register/)[Preview template](https://www.surveylegend.com/survey-examples-templates/web-forms-questionnaires/incident-report-form-template/#try-template) Preview on a device Show the desktop survey layout Show the tablet survey layout Show the mobile survey layout ![](https://www.surveylegend.com/survey-template-media/demo-backgrounds/incident-report-form-template-background.avif) **SurveyLegend** 1 / 7 Incident Report Form When did the event occur, as closely as you can recall? Your answer… Next → Incident Report Form [Preview](https://www.surveylegend.com/survey-examples-templates/web-forms-questionnaires/incident-report-form-template/#try-template) Share [Facebook ](https://www.facebook.com/sharer/sharer.php?u=https%3A%2F%2Fwww.surveylegend.com%2Fsurvey-examples-templates%2Fweb-forms-questionnaires%2Fincident-report-form-template%2F)[LinkedIn ](https://www.linkedin.com/sharing/share-offsite/?url=https%3A%2F%2Fwww.surveylegend.com%2Fsurvey-examples-templates%2Fweb-forms-questionnaires%2Fincident-report-form-template%2F)[X ](https://x.com/intent/tweet?url=https%3A%2F%2Fwww.surveylegend.com%2Fsurvey-examples-templates%2Fweb-forms-questionnaires%2Fincident-report-form-template%2F\&text=Incident%20Report%20Form%20Template)[Reddit](https://www.reddit.com/submit?url=https%3A%2F%2Fwww.surveylegend.com%2Fsurvey-examples-templates%2Fweb-forms-questionnaires%2Fincident-report-form-template%2F\&title=Incident%20Report%20Form%20Template) An incident report form records what happened, where and when it occurred, and what actions were already taken. Use these seven optional example fields to prepare a factual account for the appropriate reviewer. A useful first report separates observations from assumptions. The person completing it may know the time and location without knowing the cause. Create the form in SurveyLegend and connect any real use to your organization's approved reporting process. ## When to Use This Template Use this example to plan initial workplace incident intake after immediate help has been arranged through the proper channels. It does not decide fault or replace required incident records. A complaint about service or a general suggestion has a different purpose; choose the appropriate option from SurveyLegend's [web forms ](https://www.surveylegend.com/survey-examples-templates/web-forms-questionnaires/). **Create your incident report form in SurveyLegend** A useful first report separates observations from assumptions. The person completing it may know the time and location without knowing the cause. ## 7 Incident Report Form Questions This is a demonstration, not an emergency or real incident-reporting channel. Use your organization's approved route for an actual event. All example fields are optional. Describe only what you know; do not enter medical details, identity documents or private information about other people. Try the survey ## A little feedback. A clearer picture. Explore this 7-question example at your own pace. Every question is optional. Preview on a device Show the survey at full desktop width Resize the survey to a tablet-width preview Resize the survey to a mobile preview with scrolling inside the frame Choose a look Use Classic: a white survey card over the background photo Use Light: dark text over a light tint covering the background photo Use Dark: light text over a dark tint covering the background photo SurveyLegend demo Question 1 of 7 ### Incident Report Form 01 When did the event occur, as closely as you can recall? Share your answer, or skip this question. 02 Where did the event occur? Share your answer, or skip this question. 03 Which description best fits the event? Choose one answer, or skip this question. A near miss with no known harm Equipment or property damage An event involving possible injury Another event Not sure 04 What did you directly observe? Share your answer, or skip this question. 05 What action was taken immediately afterward? Share your answer, or skip this question. 06 Which responsible team or role has already been notified? Share your answer, or skip this question. 07 How may the authorized reviewer contact you for clarification, if you wish? Share your answer, or skip this question. #### One last look Review your answers before submitting this demo. 0 answered #### Thank you for trying the survey! You’ve tried the template from the respondent’s side. Make it your own with SurveyLegend. [Create your own survey](https://www.surveylegend.com/register/) Checking submission availability… This is a demo. We count starts and submissions only. Your answers stay in your browser and are never sent or saved. **—**Starts **—**Submissions Activity is temporarily unavailable. ## How to Adapt the Questionnaire State the real reporting route and the people responsible for reviewing reports. Supply the date format, time zone and workplace location conventions. Keep the description neutral: ask what was observed instead of who was to blame. SurveyLegend's guidance on [open-ended questions ](https://www.surveylegend.com/customer-insight/open-ended-survey-questions/)can help write prompts that leave room for an incomplete but useful account. Confirm organizational and applicable reporting requirements before operational use. ## When to Ask An online form must not delay immediate assistance or the required notification route. For routine documentation, capture the account while details are still available and allow later corrections to be distinguished from the original report. ## How to Use the Responses Have an authorized reviewer check the account and any separate evidence. Preserve uncertainty and distinguish observations, reported information and conclusions. A rise in reports may reflect easier reporting rather than more events; fewer reports do not prove a safer workplace. This form supplies no severity score, causal finding or compliance certification. ## What the Research Adds Chen and colleagues' 2013 study of 135 construction workers identified “fear of negative consequences” among reasons for not reporting injuries. [Read the study ](https://stacks.cdc.gov/view/cdc/200308). That finding makes a clear, respectful reporting process relevant to this form's introduction and follow-up. The study does not validate these fields or show that a form alone prevents under-reporting. ## Frequently asked questions ### Is this an emergency reporting tool? No. Use the established emergency and immediate-notification routes. This example is for planning documentation. ### Should a reporter guess the cause? No. Record what was observed and state uncertainty. Investigation and conclusions belong to the authorized review process. ### Does this replace a required workplace report? No. The organization must check its reporting requirements and approved systems before using any adapted form. ## Printable Incident Report Form Keep a printable version available where the approved workflow permits paper reporting. Explain how to deliver it promptly to an authorized reviewer and store it appropriately. Paper responses need separate review or manual entry; they are not automatically added to online results. ![First page of the printable Incident Report Form Template with questions and answer spaces](https://www.surveylegend.com/survey-template-media/pdf-previews/incident-report-form-template-pdf-preview.avif) [![](https://www.surveylegend.com/user-guide-media/icons/download-pdf.svg) Download the questionnaire](https://www.surveylegend.com/downloads/survey-templates/incident-report-form-template.pdf) Export Incident Report Form as PDF ## AI Prompt: Incident Report Form Copy this incident report form prompt into an AI assistant to prepare the questionnaire. 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