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)?

Are you reporting an incident affecting multiple individuals?

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?

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?

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?

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

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

Was professional medical attention or first aid required?

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

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?

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

Rate the impact on various business continuity aspects

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

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

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

Was work activity stopped or suspended due to this incident?

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

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

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

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?

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

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?

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

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

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)?

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?

Is additional equipment or resources needed to prevent similar incidents?

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

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?

Signature of person completing this report

Final submission timestamp