TEMPLATE

Hawaii incident report template

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Your Hawaii incident report has 5 rules to meet. ReportDraft puts every one on your checklist and checks your draft before you sign.

  • A report to the director within 7 working days for a day off or treatment beyond first aid
  • A death notified to the department in the county within 48 hours
  • The employee sent a copy of the report

An incident report template set up for Hawaii, with fields for the reported to HIOSH (date, time, how), report of injury to the director (date) and property damage (as the notes give it). In Word and PDF.

See a free preview filled from sample notes

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Hawaii Incident report Template
Company or organization
Site address or location
Date of the incident
Type of incident
Completed by
Reported to HIOSH (date, time, how)
Report of injury to the director (date)
Property damage (as the notes give it)
Download in Word or PDFIncluded with ReportDraft Safety and its free trial.

Hawaii rules for this report

These rules are about how and when you report, not the template's fields. Check them before you deliver.

  • A work-related death is reported to HIOSH within 8 hours, and an in-patient hospitalization, an amputation, the loss of an eye, or property damage over 25,000 dollars from a work-related incident within 24 hours, orally by telephone to (808) 586-9102 or in person at the HIOSH office in Honolulu; when the office is closed, a phone message on that number counts only if it gives all the information the rule requiresHaw. Admin. R. 12-52.1-1 (a), (e), (f) (effective 2018-10-27)
  • Every employer keeps a record of all work injuries known to it, and within seven working days of learning of an injury that causes an absence of one day or more or needs medical treatment beyond ordinary first aid, reports it to the director on the director's form: the employer's name, address and business; the employee's name, age, sex, wages and occupation; the date and hour of the accident; and the nature and cause of the injuryHRS 386-95
  • When an injury causes immediate death, the employer notifies a representative of the department in the county where it happened, personally or by telephone, within forty-eight hoursHRS 386-95
  • The employer sends the injured employee copies of every report filed with the director, except reports of fatal injuriesHRS 386-95
  • By January 31 each year the employer reports each injury on which it is still paying compensation, and within thirty days after the final payment it files a final report; wilfully failing to file a report or give a required notice can bring a fine of up to 5,000 dollarsHRS 386-95

What is in it

  • What happenedWhat the person was doing just before the incident, with the tools, equipment or material used, then how the incident happened, in the order it happened.
  • Injury or illness and treatmentThe part of the body affected and how, the object or substance that directly caused harm, and the first aid or medical treatment given and where.
  • Damage to property, equipment or the environmentWhat was damaged, spilled or released, and how much, as the notes give it.
  • Immediate actions takenWhat was done right away: first aid, emergency calls, the area made safe, equipment stopped or tagged out, and who was notified.
  • CausesThe immediate cause and any underlying causes the notes identify: equipment, procedures, training, work conditions, supervision. Only what the notes support.
  • Witness statementsName, Role, What they saw or said
  • Corrective actionsAction, Responsible, Due, Status

Rules last reviewed October 13, 2026. Read the full Hawaii incident report requirements.