Version 1.0
Prepared by: @Lorraine Sebata
Approved by: @Feli Capron @Samia Thompson
Reviewed date: 2025-12-19
Next review date: 2026-12-18

This comprehensive incident reporting form documents, classifies, and tracks workplace incidents across physical security, financial, IT, conduct, and compliance categories. It ensures proper documentation, management review, and implementation of corrective actions to prevent future occurrences.

Section 1: General Incident Information

Report Date:	____________________________	Report Prepared By:	____________________________
Incident Date:	____________________________	Incident Time (Approx.):	____________________
Location of Incident:	☐ Main Office (Specify Area): _______________________ ☐ Client Site ☐ IT System/Online ☐ Other: _____________________________

Section 2: Incident Classification (Check ALL that apply)

Category	Specific Type of Incident	Check
A. Physical Security & Safety	Break-in/Forced Entry	☐
	Property Damage (Vandalism, Accident)	☐
	Fire/Smoke Damage	☐
	Workplace Accident/Injury (Slip, Fall, etc.)	☐
	Medical Emergency (Non-Workplace Injury)	☐
B. Financial, Fraud, & Theft	Cash Missing/Internal Theft	☐
	Client Fraud (Attempted or Actual)	☐
	External Theft/Robbery (Threat of force)	☐
	AML/CTF Compliance Breach	☐
C. IT & Data	System Failure/Outage (e.g., Internet, LMS)	☐
	Data Breach (Unauthorized access to client data)	☐
	Virus/Malware/Phishing Attack	☐
D. Conduct & Conflict	Verbal Threat/Harassment	☐
	Staff vs. Staff Conflict	☐
	Staff vs. Client Conflict	☐
E. Other	Compliance/Regulatory Violation (Specify): _____________________________	☐

Section 3: Narrative & Description of Incident

Describe exactly what happened in chronological order. Include the root cause, if known. Be factual and avoid opinions.

_____________________________________________________________________________________ _____________________________________________________________________________________ ______________________________________________________________________________

Section 4: Witnesses, Victims, and Involved Parties

Name (or Position)	Contact / Employee ID	Role (Victim, Witness, Perpetrator, etc.)

Section 5: Actions Taken & Follow-Up

Immediate Actions Taken (By Reporter):	Reported To (Name & Position):
_______________________________________________________	_______________________________________________________
Police Notified? ☐ Yes (Case/Report #:_____________________) ☐ No	Insurance Claim Filed? ☐ Yes ☐ No
IT Security Notified? ☐ Yes ☐ N/A	Legal Counsel Notified? ☐ Yes ☐ No

Section 6: Management Review (To be completed by Office Manager/Branch Head)

Reviewer Name:	____________________	Date Reviewed:	____________________
Was the incident adequately addressed?	☐ Yes ☐ No	Preventative Action Required?	☐ Yes ☐ No

Corrective/Preventative Actions (e.g., disciplinary action, policy change, security upgrade): ____________________________________________________________________________________________________________________________________________________________

Manager Signature: ___________________________ Date: _________________