Sample Incident Review form

Last Updated 08/19/2020

After a workplace injury or when an employee fails to follow safety protocols an employer conducts an incident review, and if applicable, employee discipline. IMWCA’s Safety and Risk Improvement team often speaks about “incident review,” while human resource professionals may also bring up the topic of employee discipline. Both are important and may even overlap, but these procedures should differ in goals and how they are carried out.

The goal of conducting an incident review is to learn what happened that led to either a “near miss” or actual employee injury and to identify/implement strategies to prevent the incident from reoccurring.

Incident review seeks to identify all contributing factors that resulted in the near miss or employee injury. The incident review is not intended to administer employee discipline. Rather, the review will look at a wide range of issues that could include any or all of the following: hazard identification process, policies and procedures, equipment condition, equipment maintenance records, site conditions, employee training, use of personal protective equipment, management commitment, applicable claims and safety records, and employee(s) actions.

This sample form provides a structure that employers can use to gather detailed information regarding an incident. The form is meant to be used by the supervisor of the injured employee, safety coordinators or other responsible for incident review.

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