Incident Report Form Template

<form action="https://splitforms.com/api/submit" method="POST">
  <input type="hidden" name="access_key" value="YOUR_ACCESS_KEY">
  <input type="hidden" name="subject" value="New incident report">
  <input type="hidden" name="form_loaded_at" id="form_loaded_at">

  <fieldset>
    <legend>Who is reporting</legend>
    <label>Your full name <input type="text" name="reporter_name" autocomplete="name" required></label>
    <label>Email <input type="email" name="email" autocomplete="email" required></label>
    <label>Phone <input type="tel" name="phone" autocomplete="tel"></label>
    <label>You are a
      <select name="reporter_role" required>
        <option value="">Choose one</option>
        <option>Employee</option>
        <option>Contractor</option>
        <option>Visitor or customer</option>
        <option>Tenant or resident</option>
        <option>Other</option>
      </select>
    </label>
  </fieldset>

  <fieldset>
    <legend>When and where</legend>
    <label>Date of the incident <input type="date" name="incident_date" required></label>
    <label>Approximate time <input type="time" name="incident_time"></label>
    <label>Exact location
      <input type="text" name="location" placeholder="Building, floor, room or area" required>
    </label>
    <label>Type of incident
      <select name="incident_type" required>
        <option value="">Choose one</option>
        <option>Injury or illness</option>
        <option>Near miss (no one hurt)</option>
        <option>Property or equipment damage</option>
        <option>Security, theft or vandalism</option>
        <option>Vehicle</option>
        <option>Other</option>
      </select>
    </label>
  </fieldset>

  <fieldset>
    <legend>What happened</legend>
    <label>Describe what happened, in order
      <textarea name="description" rows="6" required
        placeholder="What were people doing just before? What happened? What happened right after?"></textarea>
    </label>
    <label>People involved (names and roles)
      <textarea name="people_involved" rows="3"></textarea>
    </label>
    <label>Witnesses (names and phone or email)
      <textarea name="witnesses" rows="3"></textarea>
    </label>
  </fieldset>

  <fieldset>
    <legend>Was anyone hurt?</legend>
    <label><input type="radio" name="injury" value="no" required> No</label>
    <label><input type="radio" name="injury" value="yes"> Yes</label>
    <label><input type="radio" name="injury" value="not sure"> Not sure</label>
    <label>If yes, one line only (for example "cut to left hand"). No medical records or diagnoses.
      <input type="text" name="injury_summary" maxlength="200">
    </label>
    <label>Care given
      <select name="care_given">
        <option>None needed</option>
        <option>First aid on site</option>
        <option>Sent to a clinic or hospital</option>
        <option>Not known</option>
      </select>
    </label>
  </fieldset>

  <label>Damage to property or equipment (if any)
    <textarea name="property_damage" rows="3"></textarea>
  </label>

  <label>Actions taken so far
    <textarea name="actions_taken" rows="3" required
      placeholder="Area closed off, spill cleaned, supervisor told, equipment tagged out..."></textarea>
  </label>

  <label>Supervisor or manager told (name)
    <input type="text" name="supervisor_notified">
  </label>

  <label><input type="checkbox" name="confirmed" value="yes" required>
    This report is accurate to the best of my knowledge.</label>

  <label>Type your full name to confirm
    <input type="text" name="typed_name" required>
  </label>

  <!-- honeypot: leave empty -->
  <input type="checkbox" name="botcheck" style="display:none" tabindex="-1" autocomplete="off">

  <button type="submit">Submit incident report</button>
</form>
<script>
  document.getElementById('form_loaded_at').value = Date.now();
</script>