General Incident Loss Report

1. General Information

• Reported By: [Name of the individual reporting the incident]
• Contact Information: [Phone number, email address]
• Department/Area Involved: [Relevant department/area]
• Incident ID/Reference Number: [Generated ID/reference number]

2. Incident Description

• Incident Type: [e.g., fire, theft, equipment failure, etc.]
• Description:
  Provide a brief yet comprehensive description of the incident, including what happened, how it happened, and any contributing factors.

3. Affected Parties

• Persons Involved: [List names and roles, e.g., employees, visitors, contractors]
• Injuries: [Detail injuries sustained, if any, and actions taken]
• Witnesses: [List witnesses, with contact details]

4. Loss/Damage Details

• Property/Asset Damage:
  • Items Affected: [e.g., equipment, structures]
  • Estimated Value of Damage: [Estimated monetary loss]
  • Extent of Damage: [Minor, major, total loss]
• Operational Impact:
  Detail the impact on operations, including downtime or productivity loss.

5. Actions Taken

• Immediate Response: [Actions taken immediately following the incident, such as first aid, containment, etc.]
• Authorities Notified: [Specify any internal or external authorities contacted, e.g., HR, police, fire department]
• Preventive Measures: [Outline steps taken to prevent recurrence]

6. Root Cause Analysis (Optional)

• Preliminary Findings: [Identify any potential root causes or contributing factors]
• Corrective Actions Planned: [Proposed solutions or changes to policies, training, or equipment]

7. Attachments (if applicable)

• Photos: [Yes/No – attach photographic evidence]
• Witness Statements: [Yes/No – attach written statements from witnesses]
• Relevant Documents: [Yes/No – attach any relevant reports, invoices, etc.]

8. Final Remarks

• Prepared By: [Name and designation of the person preparing the report]
• Date of Submission: [Insert date here]
• Reviewed By: [Name and designation of reviewer]