Emergency Incident Report Template

Instructions for Use

Purpose: Document actual emergency incidents to capture facts, analyze root causes, implement corrective actions, and fulfill regulatory reporting requirements.

How to Complete:

1. Immediate Reporting: Complete Section 1 (Incident Details) and Section 2 (Immediate Actions) as soon as the incident is under control
2. Initial Report: Submit to Environmental Lead and Management within 24 hours of incident
3. Full Investigation: Complete remaining sections within 7 days (or as appropriate to incident severity)
4. Root Cause Analysis: Use appropriate methodology (5 Whys, Fishbone, etc.) to determine root cause
5. Corrective Actions: Define specific, measurable actions with responsible parties and deadlines
6. Regulatory Reporting: Identify if external reporting required and ensure compliance with deadlines
7. Follow-Up: Track corrective actions to completion; review effectiveness
8. Closure: Close incident only when all actions completed and verified effective

When to Use:

• Actual emergency incidents (fire, spill, injury, environmental release, facility damage, etc.)
• Near-miss incidents with potential for serious consequences
• Incidents requiring regulatory notification
• Any incident triggering emergency response procedures

Severity Classification:

• Critical: Fatality, serious injury requiring hospitalization, major environmental damage, significant property loss, major service disruption
• Major: Injury requiring medical treatment, moderate environmental impact, significant property damage, extended service disruption
• Moderate: Minor injury (first aid), minor environmental impact, limited property damage, brief service disruption
• Minor: No injury, negligible environmental impact, minimal property damage, no service disruption

Confidentiality: This report may contain sensitive information. Distribute only to authorized personnel. Follow data protection requirements.

Owner: Environmental Lead (environmental/safety incidents), CISO (information security incidents - see SW-ISMS-PRO-001)

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Emergency Incident Report

1. Incident Identification

Field	Information
Incident ID	[Auto-generate: INC-YYYY-MM-NNN]
Report Date	[YYYY-MM-DD]
Incident Date	[YYYY-MM-DD]
Incident Time	[HH:MM] (24-hour format)
Reported By	[Name and role of person filing this report]
Contact Information	Phone: [Number]
Discovery Date/Time (if different)	[YYYY-MM-DD HH:MM]
Discovered By	[Name and role of person who discovered incident]

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2. Incident Classification

Incident Type (select all that apply):

[ ] Fire
[ ] Medical Emergency / Injury
[ ] Environmental Spill or Release
[ ] Hazardous Substance Exposure
[ ] Flood / Water Damage
[ ] Power Outage
[ ] Severe Weather / Natural Disaster
[ ] Facility Damage (structural, equipment)
[ ] Workplace Violence / Security Threat
[ ] IT / Cybersecurity Incident (if environmental/physical impact - otherwise use SW-ISMS-PRO-001)
[ ] Data Center Incident
[ ] Other: _______________________________

Incident Severity:
[ ] Critical
[ ] Major
[ ] Moderate
[ ] Minor
[ ] Near-Miss (no actual impact but potential for serious consequences)

Incident Category:
[ ] Environmental
[ ] Occupational Health & Safety
[ ] Quality / Customer Impact
[ ] Security / Safety
[ ] Business Continuity
[ ] Multiple categories (specify): _______________

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3. Location and Context

Incident Location:
[ ] Karlstad Office
[ ] Stockholm Office
[ ] Uddevalla Office
[ ] Customer Site (specify): _________________
[ ] Remote/Home Office (specify): ___________
[ ] Data Center (Entiros AB)
[ ] Other: ______________________________

Specific Location Details:

• Building/Floor: [Details]
• Room/Area: [Details]
• Coordinates (if outdoor): [Coordinates]

Environmental Conditions (if relevant):

• Weather: [Conditions at time of incident]
• Temperature: [If relevant]
• Lighting: [If relevant]
• Other: [Noise, visibility, etc.]

Operational Context:

• Normal operations: [ ] Yes [ ] No
• If No, describe: [Maintenance, startup, shutdown, abnormal conditions, etc.]
• Time of day: [ ] Working hours [ ] After hours [ ] Weekend/Holiday

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4. Incident Description

What Happened (factual description - who, what, when, where, how):

[Provide detailed, factual account of the incident. Include:

• Sequence of events leading to incident
• What happened during the incident
• How the incident was discovered
• Who was involved or affected
• Equipment or materials involved
• Approximate timeline of events]

Immediate Impact:

Impact Type	Yes/No	Description
Injury/Illness	[ ] Yes [ ] No	[Number of people affected, nature of injuries]
Environmental Impact	[ ] Yes [ ] No	[Type and extent of environmental damage or release]
Property Damage	[ ] Yes [ ] No	[Equipment, facilities, vehicles damaged; estimated value]
Service Disruption	[ ] Yes [ ] No	[Services affected, duration of disruption, customers impacted]
Data Loss/Breach	[ ] Yes [ ] No	[Data affected, systems impacted]
Business Interruption	[ ] Yes [ ] No	[Operations halted, duration, financial impact]

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5. Persons Involved

5.1 Injured or Affected Persons

Name	Role	Nature of Injury/Illness	Medical Treatment Required	Status
[Name]	[Employee, Contractor, Visitor, etc.]	[Description]	[ ] None [ ] First Aid [ ] Medical Center [ ] Hospital	[Returned to work, on sick leave, hospitalized, etc.]
[Name]

Next of Kin Notified: [ ] Yes [ ] No [ ] N/A
Occupational Safety Authority Notified (if serious work injury): [ ] Yes [ ] No [ ] N/A

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5.2 Witnesses

Name	Role	Contact	Statement Taken
[Name]	[Role]	[Phone/Email]	[ ] Yes [ ] No
[Name]

Witness Statements: [ ] Attached [ ] On file [ ] N/A

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5.3 Responders

Name	Role	Actions Taken
[Name]	[First Aider, Fire Warden, Incident Commander, etc.]	[Summary of response actions]
[Name]

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6. Immediate Actions Taken

Initial Response (within first minutes):

1. [Action taken - e.g., "Called 112 for ambulance"]
2. [Action taken - e.g., "Evacuated building"]
3. [Action taken - e.g., "Contained spill using spill kit"]
4. [Action taken]

Emergency Services Response (if applicable):

Service	Arrival Time	Actions Taken	Clearance/Departure Time
Fire Brigade	[HH:MM]	[Summary]	[HH:MM]
Ambulance	[HH:MM]	[Summary]	[HH:MM]
Police	[HH:MM]	[Summary]	[HH:MM]
Other: _____	[HH:MM]	[Summary]	[HH:MM]

Incident Commander: [Name and role]
Incident Declared Controlled: [Date and time]
All Clear Given: [Date and time]

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7. Environmental Impact Assessment

Environmental Aspect Affected (if applicable):

[ ] Air emissions (smoke, fumes, odor)
[ ] Water pollution (spill to drain, watercourse, groundwater)
[ ] Soil contamination
[ ] Noise pollution
[ ] Waste generation (hazardous or non-hazardous)
[ ] Resource consumption (water, energy)
[ ] Other: _______________________
[ ] None (no environmental impact)

Environmental Impact Details:

Aspect	Substance/Material Involved	Quantity Released	Area Affected	Extent of Impact
[e.g., Water pollution]	[e.g., Cleaning chemical]	[e.g., 2 liters]	[e.g., Sink drain]	[e.g., Contained, did not reach watercourse]

Containment and Cleanup:

• Actions taken: [Describe containment and cleanup measures]
• Materials used: [Absorbents, barriers, equipment]
• Waste generated: [Type and quantity of contaminated materials]
• Disposal method: [How waste was disposed - e.g., hazardous waste contractor]
• Effectiveness: [ ] Fully contained [ ] Partially contained [ ] Not contained

Long-Term Environmental Impact: [ ] Yes [ ] No [ ] Unknown
If Yes, describe: [Ongoing monitoring, remediation required, etc.]

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8. Regulatory and External Reporting

Regulatory Reporting Required:

Authority/Regulation	Required?	Deadline	Reported By	Report Date	Confirmation #
Swedish Work Environment Authority (Arbetsmiljöverket) - Serious work injury	[ ] Yes [ ] No	Within 24 hours	[Name]	[Date]	[Reference]
Environmental Authority (municipality or Naturvårdsverket) - Environmental incident	[ ] Yes [ ] No	Immediate or ASAP	[Name]	[Date]	[Reference]
Swedish Authority for Privacy Protection (IMY) - Data breach (GDPR)	[ ] Yes [ ] No	Within 72 hours	[Name]	[Date]	[Reference]
Building/Fire Authority - Fire incident	[ ] Yes [ ] No	[Per local requirement]	[Name]	[Date]	[Reference]
Insurance Company	[ ] Yes [ ] No	Per policy	[Name]	[Date]	[Reference]
Other: ___________	[ ] Yes [ ] No

Regulatory Reporting Responsibility: Environmental Lead (environmental/safety), CISO (data protection/security), HR (occupational safety)

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9. Customer and Stakeholder Communication

Were Customers Affected: [ ] Yes [ ] No

If Yes:

• Number of customers affected: [Number]
• Nature of impact: [Service disruption, data concern, etc.]
• Customers notified: [ ] Yes [ ] No
• Notification date/time: [Date/Time]
• Notification method: [ ] Email [ ] Phone [ ] Portal notification [ ] Other: _______
• Customer Success Manager informed: [ ] Yes [ ] No

Other Stakeholders Notified:

Stakeholder	Notified?	Date	Method
Management Team	[ ] Yes [ ] No	[Date]	[Email, phone, meeting]
All Staff	[ ] Yes [ ] No	[Date]	[Teams, email]
Building Management	[ ] Yes [ ] No	[Date]
Data Center (Entiros AB)	[ ] Yes [ ] No	[Date]
Supplier: ________	[ ] Yes [ ] No	[Date]
Media	[ ] Yes [ ] No	[Date]	[Via CEO only]

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10. Root Cause Analysis

Analysis Method Used:
[ ] 5 Whys
[ ] Fishbone Diagram (Cause and Effect)
[ ] Fault Tree Analysis
[ ] Timeline Analysis
[ ] Other: __________________

Root Cause Determination:

Immediate Cause(s) (direct trigger of incident):
[What directly caused the incident to occur - e.g., "Electrical fault in equipment"]

Underlying Cause(s) (contributing factors):
[What allowed the immediate cause to occur - e.g., "Lack of preventive maintenance"]

Root Cause(s) (systemic or organizational factors):
[Fundamental reason why incident occurred - e.g., "No preventive maintenance schedule for electrical equipment"]

Contributing Factors:

• Equipment failure
• Human error
• Inadequate procedure
• Lack of training
• Poor communication
• Inadequate supervision
• Environmental factors
• Design flaw
• Lack of resources
• Other: _________________

5 Whys Analysis (if used):

1. Why did the incident occur? [Answer]
   • Why? [Answer]
     • Why? [Answer]
       • Why? [Answer]
         • Why? [Answer] ← Root Cause

Fishbone Diagram: [ ] Attached [ ] Not used

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11. Risk Assessment

Likelihood of Recurrence (without corrective action):
[ ] Very Likely (will occur again soon)
[ ] Likely (will probably occur again)
[ ] Possible (might occur again)
[ ] Unlikely (probably won't occur again)
[ ] Rare (very unlikely to occur again)

Potential Consequence if Recurs:
[ ] Catastrophic (fatality, major environmental disaster, business closure)
[ ] Major (serious injury, significant environmental damage, major financial loss)
[ ] Moderate (injury, moderate environmental impact, significant cost)
[ ] Minor (minor injury, minor environmental impact, low cost)
[ ] Negligible (no real impact)

Risk Level: [Likelihood × Consequence = Risk rating per SW-IMS-PRO-002]

Is this incident related to a previously identified risk?
[ ] Yes - Risk ID: [Reference]
[ ] No - New risk identified

Should this risk be added to Risk Register?
[ ] Yes [ ] No
If Yes, Risk Owner: [Name/Role]

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12. Corrective Actions

Immediate Corrective Actions (already taken to prevent recurrence):

Action	Responsible	Completion Date	Status
[Action description]	[Name/Role]	[YYYY-MM-DD]	[ ] Completed [ ] In Progress
[Action description]	[Name/Role]	[YYYY-MM-DD]	[ ] Completed [ ] In Progress

Planned Corrective Actions (to address root cause and prevent recurrence):

Action #	Corrective Action	Responsible Person	Target Date	Priority	Status	Verification Method
CA-1	[Specific action to address root cause]	[Name/Role]	[YYYY-MM-DD]	[ ] High [ ] Medium [ ] Low	[ ] Open [ ] In Progress [ ] Completed	[How will effectiveness be verified]
CA-2
CA-3
CA-4

Corrective Action Tracking: Actions tracked per SW-IMS-PRO-005 (Nonconformity and Corrective Action Procedure)

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13. Preventive Actions

Preventive Actions (proactive measures to prevent similar incidents in other areas):

Action	Scope/Application	Responsible	Target Date	Status
[Action - e.g., "Inspect all similar equipment"]	[Where to apply - all offices, specific area]	[Name/Role]	[YYYY-MM-DD]	[ ] Open [ ] Completed

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14. Procedure and Document Updates

Do procedures or documents need updating based on this incident?
[ ] Yes [ ] No

If Yes, identify updates required:

Document	Update Required	Responsible	Target Date	Status
[Document ID and name]	[Description of change]	[Name/Role]	[YYYY-MM-DD]	[ ] Open [ ] Completed

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15. Lessons Learned

Key Lessons:

1. [What did we learn from this incident?]

What Worked Well:
[Positive aspects of the response - procedures, training, equipment, team coordination that were effective]

What Could Be Improved:
[Aspects of response or preparedness that could be enhanced]

Best Practices Identified:
[Practices to document and share across organization]

Training Needs Identified:
[Gaps in knowledge or skills revealed by incident]

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16. Cost and Impact Summary

Financial Impact:

Cost Category	Estimated Cost (SEK)	Actual Cost (SEK)
Medical/Injury costs
Property damage/repair
Equipment replacement
Environmental cleanup
Service disruption/lost revenue
Regulatory fines/penalties
Legal costs
Overtime/contractor costs
Other: ____________
TOTAL

Insurance Claim: [ ] Yes [ ] No
If Yes, Claim #: [Reference] | Status: [Pending, Approved, Paid]

Downtime:

• Service interruption duration: [Hours/days]
• Staff time lost: [Person-hours]
• Customer accounts affected: [Number]

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17. Post-Incident Review Meeting

Review Meeting Held: [ ] Yes [ ] No [ ] Scheduled for: [Date]

Attendees:

• [Name - Role]
• [Name - Role]
• [Name - Role]

Review Outcomes:
[Summary of discussion, decisions made, additional actions identified]

Meeting Minutes: [ ] Attached [ ] On file

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18. Incident Closure

All Corrective Actions Completed: [ ] Yes [ ] No

Corrective Actions Verified Effective: [ ] Yes [ ] No

Risk Level After Corrective Actions: [Reassess risk with controls in place]

Incident Closure Approved: [ ] Yes [ ] No

Closed By: [Name/Role]
Closure Date: [YYYY-MM-DD]

Closure Comments:
[Summary of incident resolution, confirmation of effectiveness, any ongoing monitoring required]

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19. Signatures and Approvals

Report Prepared By:

Name	Role	Signature	Date
[Name]	[Investigator/Reporter]		[YYYY-MM-DD]

Reviewed By:

Name	Role	Signature	Date
[Name]	Environmental Lead / CISO / HR (as applicable)		[YYYY-MM-DD]
[Name]	Incident Commander		[YYYY-MM-DD]

Approved By:

Name	Role	Signature	Date
[Name]	Management Team Representative		[YYYY-MM-DD]

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20. Distribution and Filing

Report Distribution:

• Environmental Lead
• CISO (if IT/security related)
• HR (if injury/occupational safety)
• Office Manager (relevant location)
• Management Team
• Legal Counsel (if required)
• Insurance Company (if claim)
• Affected parties (as appropriate)

Confidentiality Level: [ ] Internal [ ] Confidential [ ] Restricted

Filed in: [Document management system location/folder]
Related Records: [Link to witness statements, photos, external reports, etc.]

Retention: 7 years (or per legal requirements for specific incident types)

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Attachments

Attach supporting documentation:

• Photographs (incident scene, damage, equipment)
• Witness statements
• External agency reports (fire brigade, ambulance, police)
• Medical reports (if applicable and permitted)
• Environmental test results (soil, water samples if taken)
• Equipment inspection/failure analysis reports
• Correspondence (regulatory authorities, customers, insurance)
• Corrective action tracking records
• Other: _______________________________

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Document Control

Version	Date	Author	Changes
1.0	[TBD]	[Author]	Initial release

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Approval

Role	Name	Signature	Date
Environmental Lead
Management Team Representative