Employee Incident Report
Your Details
Employee Name
*
First Name
Last Name
Phone Number
*
Email
*
example@example.com
Type a question
Please Select
Back
Next
Employee Incident Report
Incident Details
Date and Time of Incident
*
-
Day
-
Month
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Site Incident took place
*
Eg Best and Less Bathurst
Location Incident took place
*
Eg Front Entrance of Store
Was Equipment involved?
*
Eg Yes a floor buffer
Picture of area where the incident occured
Browse Files
Eg Cleaner Room or Shop Floor
Cancel
of
Was the incident a result of a slip, trip or fall?
*
Yes
No
If yes, please describe footwear
Eg Closed in lace up rubber non slip shoes
When was the area cleaned before the incident occured
*
Eg 2 days ago at 7pm
Is there CCTV Footage of the incidient?
*
Yes
No
Name of Witness
Back
Next
Employee Incident Report
Injurty Details
Nature and body part of Injury
*
The Incident as descriped by Employee
*
Post Incident description (approx 24 hours after)
*
Was an ambulance called
*
Yes
No
Was First Aid Required
*
Yes
No
Was the Employee sent to a Hospital or Medical Centre?
*
Yes
No
Name of Hospital or Medical Centre (If any)
Report completed by Name
*
First Name
Last Name
Back
Next
Employee Incident Report
Sign Off
Please read Carefully
*
I give consent for the collection of the above information to be used or disclosed for the purpose it was collected for.
Signature
*
Submit
Should be Empty: