Workplace Incident Reporting Form
Complete each section with accuracy and detail, and submit it to the safety department within [24 hours] of the incident.
Employee Information
Employee's Full Name: | [Employee's Name] |
Job Title: | |
Department/Team: | |
Supervisor's Name: | |
Contact Information: | |
Incident Details
Date of Incident: | [Month Day, Year] |
Time of Incident: | |
Exact Location of Incident: | |
Description of the Incident: | |
Witness Information
Witness Name(s): | [Your Name] |
Contact Information: | |
Witness Account: | |
Injury Information
Nature of Injury: | Minor head contusion |
Part of Body Affected: | |
First Aid Administered: | |
Medical Attention Required: | |
Medical Facility Visited: | |
Property Damage Information
Description of Property Damage: | Minor damage to shelf corner |
Estimated Cost of Damage: | |
Immediate Actions Taken
List of immediate corrective actions: | The wet floor was cleaned immediately, and additional caution signs were placed. |
Additional Comments/Statements:
Signature of Reporting Employee:
[Your Name]
[Job Title]
[Month Day, Year]
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