Incident Report Form

Employee Incident Reporting Form
Complete this form immediately following any workplace incident, accident, near-miss, or safety concern.
Employee Information
Select Your Name*

Mackenzie ScottChloe StreifMelanie MeskerKatelyn ZenieBrittany PinterAna HurtadoNatalia BoyerRachel LevinMary HammonAdrianna CastroMaria Ganger
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?*
What task were you performing 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 injured?*

YesNoNot sure
Describe the injury.
What part of the body was affected?
Did you seek medical attention*

YesNoNot Yet
Where and when?*
Are you able to continue working at this time?*

YesNoNot sure
Property Damage
Was any client property damaged?*

YesNoN/A
Was any company equipment damaged?*

YesNoNot sureN/A
Description of damage and cost valuation, if you know.
Witnesses
Were there any witnesses?*

YesNoNot sure
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*

Clear
Should be Empty:

Employee Incident Reporting Form

Employee Information

Incident Details

Description of Incident

Injury Information

Property Damage

Witnesses

Immediate Actions Taken