Incident Report Form

Employee Incident Reporting Form
Complete this form immediately following any workplace incident, accident, near-miss, or safety concern.
For whom are you filling out this form
Employee Information
Select Your Name
Your Employee Email
Incident Details
Date of Incident

MonthDayYear
Date
Time of Incident

Hour Minutes

AM/PM Option
Client name and/or location where incident occurred
If not at a client location, type N/A.
Specific location of the incident (kitchen, stairs, basement, desk, etc.)
Weather conditions (if relevant for slips/falls)
Description of Incident
What happened? Who was involved
What task was being performed when the incident occurred?
What do you think caused the incident?
Do you think this incident could have been prevented? If so, how?
Injury Information
Were you or someone else injured?
Describe the injury.
What part of the body was affected?
Did you seek medical attention
Where and when?
Are you able to continue working at this time?
Property Damage
Was any client property damaged?
Was any company equipment damaged?
Description of damage and cost valuation, if you know.
Witnesses
Were there any witnesses?
Witness name(s)
Immediate Actions Taken
What steps were taken immediately after the incident?
Was anyone notified? (supervisor, client, emergency services)
Upload any photos of the scene or injured here
Date

MonthDayYear
Date
Signature
Should be Empty:

Employee Incident Reporting Form