Workplace Incident Report — OSHA Compliant

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Step 1 of 6 — Reporter Information

Who is submitting this report?

First Name *

Last Name *

Work Email * HRIS Auto-populated from HRIS / SSO in production

Phone (optional)

Job Title HRIS

Department * HRIS

Work Location / Facility * HRIS

I am reporting on behalf of another person

ℹ️ Enter the details of the person who experienced the incident in Step 3.

Section: Reporter Information

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Step 2 of 6 — Incident Details

What happened, where, and when?

OSHA 300 / 301

Incident Type *

Notification Urgency * AUTO

Date of Incident *

Time of Incident

Incident Site / Facility *

Specific Location Within Facility * OSHA 300: "Where the event occurred"

Incident Description * OSHA 301 0 / 50 characters minimum

Immediate Actions Taken *

Equipment / Materials Involved

🚗 Vehicle Incident Details

Fleet / Asset ID or License Plate

Vehicle Make / Model

Third Party Involved?

Yes No

🏗 Property Damage Details

Description of Damaged Property

Estimated Damage Value (USD)

♻️ Environmental Release Details

Material Released

Estimated Quantity

Media Affected (select all that apply)

Regulatory Agency Notified?

Yes No Pending

👁 Witnesses

Photos / Attachments JPEG, PNG, PDF, MP4 — up to 20 files, 50 MB each

Section: Incident Details

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Step 3 of 6 — Involved Person

Who was injured, ill, or involved?

OSHA 301 Part A

Person Type *

Employee ID HRIS Lookup Auto-populates name, department, title, hire date, supervisor

First Name *

Last Name *

Job Title * HRIS

Department * HRIS

Date of Hire OSHA 301 HRIS

Date of Birth OSHA 301 HRIS Used for OSHA Form 301 only. Kept confidential.

Gender OSHA 301 HRIS

Employment Type HRIS

Shift at Time of Incident *

Supervisor Name HRIS

Supervisor Email HRIS

Contractor Company Name *

Contractor On-Site Supervisor

OSHA Privacy Case — Suppress employee name on OSHA 300 Log (e.g., sexual assault, HIV diagnosis)

🔒 Employee name will be replaced with "Privacy Case" on the OSHA 300 Log per 29 CFR 1904.29(b)(7). Full details are maintained in the confidential OSHA 301 form.

Section: Involved Person

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Step 4 of 6 — Injury / Illness Details

Nature of injury, body part, treatment, and OSHA determination

OSHA 300 Cols G–N / 301

Type of Injury / Illness *

Side of Body

Body Area *

Specific Body Part *

Object / Substance That Caused Harm OSHA 301

What Was Employee Doing? OSHA 301

🏥 Medical Treatment

Medical Treatment Received *

Treating Facility / Physician

Date of Treatment

Days Away From Work OSHA 300 Col H Enter 0 if none. OSHA recordable if ≥ 1.

Days on Restricted / Light Duty OSHA 300 Col I

Work-Related? *

Time Employee Began Work OSHA 301

⏳ Awaiting Input

OSHA 300 Log Columns to Mark:

Col G — Death Col H — Days Away Col I — Restricted Col J — Injury

EHS Manager Override — override auto-determination (requires justification)

ℹ️ Injury/illness details are not required for this incident type. Continue to the Investigation section.

Section: Injury / Illness Details

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Step 5 of 6 — Investigation & Root Cause

Root cause analysis, corrective actions, and training requirements

Lead Investigator *

Investigator Title

Investigation Start Date

Investigation Due Date AUTO Auto-set: 5 business days from start date

🌳 Root Cause Analysis

RCA Method *

Root Cause Category *

Immediate Cause *

Root Cause Narrative *

5 Whys Analysis

Why 1?

Why 2?

Why 3?

Why 4?

Why 5?

Training Deficiency Identified — triggers LMS AI training recommendation

Describe the Training / Knowledge Gap *

🤖 AI Recommendation Engine will activate upon investigation submission. The LMS will analyze the root cause and training gap description and recommend relevant courses within 3–5 seconds.

✅ Corrective Actions

✍️ Sign-Off

⚠️ OSHA requires the investigation form to be completed within 7 calendar days of receiving information that a recordable case has occurred (29 CFR 1904.29).

Supervisor Review

Supervisor Name

Review Date

Supervisor Signature (print form to sign)

EHS Manager Approval

EHS Manager Name

Review Date

EHS Manager Signature (print form to sign)

Section: Investigation

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Step 6 of 6 — Review & Submit

Verify the information below before submitting

📧 On submission, automatic notifications will be sent to the involved employee's supervisor and the EHS Manager for the selected facility. If urgency is Immediate or High, an SMS alert will also be sent.

I certify that the information provided in this report is accurate and complete to the best of my knowledge.

Section: Review & Submit

🚗 Vehicle Incident Details

🏗 Property Damage Details

♻️ Environmental Release Details

👁 Witnesses

🏥 Medical Treatment

🌳 Root Cause Analysis

5 Whys Analysis

✅ Corrective Actions

✍️ Sign-Off

Incident Report Submitted