Remote Work Incident, Injury & Disaster Contingency Reporting Form

Date and time this report is being submitted

Date and time the incident occurred (if different from report time)

Primary classification of this report

Initial severity assessment (1 = Minimal, 5 = Critical)

Full name of person completing this report

Your relationship to the incident

Your job title or role

Your contact email address

Your direct contact phone number

Are you the immediate supervisor of the affected individual(s)?

When did you first become aware of this incident?

Name of the immediate supervisor (if known)

Are you reporting an incident affecting multiple individuals?

Details of all affected individuals

Full name of the affected individual

Job title or role of the affected individual

Department, team, or business unit

Direct supervisor or manager name

Employment start date of affected individual (if applicable)

Type of remote work location where incident occurred

Full physical address or detailed location description

Is this location address confidential or sensitive?

Was the individual working alone at the time of the incident?

Describe the communication check-in protocol in place (if any):

Who else was present and what was their role?

Select all environmental and ergonomic factors present at the location (select all that apply)

Were any of the selected environmental factors inadequate or contributing to the incident?

Describe which factors were inadequate and how they contributed:

Comprehensive description of what happened

What specific task or activity was the individual performing when the incident occurred?

Immediate cause or trigger of the incident

Select all contributing factors (select all that apply)

Was this a 'near miss' where no actual harm occurred but potential was present?

What potential consequences were avoided and how?

Could this incident have realistically occurred in a traditional office environment?

Explain how this is specific to remote work context:

Explain why this is unique to remote work settings:

Did the incident result in any physical injury, illness, or acute health condition?

Type of injury or health impact

Was there any mental health or psychological impact?

Describe the psychological impact experienced:

Was professional medical attention or first aid required?

Select all medical responses that were initiated (select all that apply)

Is the affected individual currently unable to perform their work duties?

Anticipated date of return to full duties (if known)

Describe any ongoing symptoms, treatment plan, or work restrictions:

Was this incident directly related to or triggered by a disaster, emergency, or major disruption event?

Primary disaster or emergency type

Was an official disaster contingency or business continuity plan activated in response?

Which specific contingency measures were implemented and how effective were they?

Explain why no contingency plan was activated or why one does not exist:

Rate the impact on various business continuity aspects

Did this incident require evacuation or relocation from the remote work location?

Describe evacuation process and current location of the individual:

Were immediate corrective or response actions taken at the time of the incident?

Describe all immediate actions taken and by whom:

Explain why no immediate action was possible or taken:

Select all notifications and escalations that have been completed (select all that apply)

Was work activity stopped or suspended due to this incident?

Describe what work was stopped and the current status:

Timeline of Key Response Actions

Did the incident result in damage to any equipment, technology, or property?

Detailed damage assessment

Was any sensitive or confidential company data compromised, lost, or exposed?

Describe the data involved and potential impact:

Has a backup or recovery process been initiated for any damaged technology or data?

Describe the recovery status and estimated time to full functionality:

Rate the impact on various business and operational aspects (1 = No Impact, 5 = Severe Impact)

Will this incident cause any deadlines or deliverables to be missed?

Impacted deadlines and deliverables

Have clients, customers, or external partners been notified of any impact?

Describe the communication made and client reactions (if any):

Estimated financial impact on the business (if quantifiable)

Estimated time for full operational recovery

Assess the role of various human factors in the incident

Assess the role of various environmental and technical factors

Assess the role of organizational and procedural factors

Do you believe this incident could have been prevented with existing controls and procedures?

Explain why existing controls failed to prevent the incident:

What specific controls or procedures were missing or inadequate?

Have similar incidents or near misses occurred before for this individual, team, or location?

Describe previous incidents and what was done to address them:

Were there any witnesses to the incident (including virtual witnesses)?

Witness information and statements

Upload any relevant photographs of the scene, equipment damage, or injuries (if applicable and appropriate)

Upload screenshots if incident involved technology, software, or digital systems

Upload any relevant documents such as medical reports, police reports, or insurance forms (if available)

Is there video evidence available (security camera, dashcam, screen recording)?

Describe the video evidence and how it can be accessed:

Additional notes, observations, or context not captured elsewhere:

Immediate corrective actions recommended to prevent recurrence

Select all preventive measures that should be implemented (select all that apply)

Should a formal risk assessment be conducted for this remote work setup or activity?

Specify the scope and priority of the risk assessment:

Is additional equipment or resources needed to prevent similar incidents?

Required equipment and resources

Should this incident be escalated to a higher management level or specialized committee?

Explain the escalation rationale and recommended approach:

Target date for implementing recommended preventive actions

Person or role responsible for monitoring implementation of preventive actions

I confirm that all information in this report is true and accurate to the best of my knowledge

I consent to the collection and use of this information for safety investigation and preventive action purposes

I understand that withholding or falsifying information may impede safety improvements and could be subject to review

Do you require a copy of this submitted report for your personal records?

Email address where copy should be sent (if different from reporter email):

Signature of person completing this report

Final submission timestamp