Case Report Form

A Case report form is a general-purpose report form that can be used by any government department/agency or commercial companies to make a report of a certain case. It is aimed to provide a factual report about a particular matter.

Sample Case report Form

General Information

Name of Company/Organization________________

Address___________ Phone__________ Email______ Fax_________

Report prepared by: Name________ Designation___________

Phone_________ Email_________

Case Report Information

Case Report Title___________

Report Date____/____/___ Location_______________

Purpose of Report___________

Nature of Case___________

Case Officer or Chief Investigator______________

Brief Description of Case_______________

Involved People____________________

Effected Persons___________________

Does the case caused any damage to property/people/other, if yes than provide details_________________________

Witness________________

Primary reporting of case to the_______________

Supervisor of site_____________________

Is there any compensation or reimbursement asked________________

Any legal issues aroused due to case___________________

Corrective/Preventive or any affirmative actions taken by concerned department______________________

Extra Notes, Comments__________________

Signature____________ Date of Report Submission____/____/___

Report Recipient Information

Report Addressed to______________

Name of Recipient_____________ Designation____________

Remark on Case____________

Signature_____________ Date__/___/___

Category: Report Forms