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safety

Workplace Incident Report

Captures workplace injury, illness, or near-miss facts. Feeds OSHA 301/300 and workers' comp.

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Rolled out to every employee at AutoZone (125,000), PetSmart (50,000+), A.S. Watson and Raley's (20,000) — and at larger retailers we are not permitted to name.

Built for: Manufacturing · Construction · Warehouse · Healthcare

What's inside this template

Incident Details

  • Date and time of incident (required)
  • Location of incident (required)

    Building, floor, area, equipment if applicable

  • Type of incident (required)

    Injury / Illness / Near-miss / Property damage

  • Description of what happened (required)

    Sequence of events in your own words

Affected Person

  • Name of affected person (required)
  • Job title / role (required)
  • Body part affected (if injury)
  • Severity

    First aid / Medical treatment / Lost time / Hospitalization / Fatality

  • Photo of injury or scene (if appropriate)

Witnesses & Response

  • Witness names and contact
  • First aid given?
  • EMS called?
  • Was the injured person sent to a clinic / hospital?

Reporter

  • Reporter name (required)
  • Reporter signature (required)
  • Date filed (required)

Common use cases

OSHA 301 reporting
Workers' comp claim filing
Near-miss tracking

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Workplace Incident Report runs on a platform app included with every MangoApps plan — pick a suite and it comes along.

Start free — included with every suite

Rolled out to every employee at AutoZone (125,000), PetSmart (50,000+), A.S. Watson and Raley's (20,000) — and at larger retailers we are not permitted to name.