Workplace Incident Report
EMPLOYEE REPORT
Employee name
*
First Name
Last Name
Employee phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Employee email
example@example.com
Section I. Description of Incident
Date of incident
*
.
Month
.
Day
Year
Time of incident
Office where incident occurred
*
Exact location where incident occurred (i.e., operatory, break room, parking lot, etc.)
*
Incident description:
*
Were there injuries as a result of the incident?
Yes
No
If yes, please describe the injuries:
Was medical treatment provided?
Yes
Treatment declined
Reporting only (no treatment needed)
If you received treatment, who provided it?
Provider contact:
Briefly describe result of medical examination:
Section II. Employee Acknowledgment
Employee signature
Date
Submit
Should be Empty: