Incident Report This form must be completed to record injuries and accidents, near misses, property and equipment damage, health and safety issues, security breaches and misconducts. Contact the Site Supervisor if you have any questions.Incident Report Reported By (Full Name) * Date of Report * Time of Report * Title/ Role * Incident Number (optional) Incident Information Date of Incident * Risk Rating * 54321 Check the Risk Assessment Process (Source: HIA Safety) Incident Type * SafetyEnvironmental Environmental Incident Type Air PollutionFlora/FaunaNoise PollutionSoil PollutionWater PollutionOther Environmental Incident TypeLocation Location Location Location City City State State Postcode Postcode Specific Area of Location (if Applicable) Incident Description Name/Role/Contact of Parties Involved Name Role Phone plus1 Add minus1 RemoveName/Role/Contact of Witnesses Name Role Phone plus1 Add minus1 RemovePolice Report Filed? N/A Yes NoPolice Details Precinct Reporting Office Phone Follow Up Action Date Supervisor Name Supervisor Signature signature keyboard Clear Submit If you are human, leave this field blank.