HS Incident Report Form

This form can be used by employees, witnesses, or supervisors to keep an informal record of an incident, injury, or near miss in the workplace.

It provides space to document what happened, when it occurred, who was involved, and any immediate actions taken.

Please note: This form does not replace any reporting or documentation required by WorkSafeBC. Employers must still complete and submit all mandatory WorkSafeBC forms when applicable.

When to use this form

• To record minor incidents that do not require formal investigation
• To capture details of a near miss for internal tracking and prevention
• To support follow up conversations with workers or supervisors
• To document early information before completing official reports

What this form includes

• Basic incident details
• Description of what happened
• Names of individuals involved or witnessing the incident
• Immediate actions taken
• Signatures for verification

Use this form as part of your internal Health and Safety practices to support consistent reporting and follow up.