Employee Incident Form

Employee Incident Form
Instructions: Employees shall use this form to report all work related incidents which caused or could have caused injury, consumers power interruption, or illness - no matter how minor. This helps us to identify and correct possible hazards that could lead to more incidents in the future. This form shall be completed by employees as soon as possible and given to a supervisor for further action.
Your Name:*

First NameLast Name
Email:*
example@example.com
Job Title:*
Supervisor:*
Have you told your supervisor about this incident?*
Date of incident:*

MonthDayYear
Date
Time of incident:*

Hour Minutes

AM/PM Option
Where, exactly, did it happen?*
What were you doing at the time?*
Describe step by step what led up to the incident:*
What could have been done to prevent this incident:*
Upload Pictures:

Cancelof
Should be Empty: