Lumiform Mobile audits & inspections
Get App Get App

Employee Incident Report

Employees can use this form to report all work-related injuries, illnesses, or near-miss events no matter how minor. This template is an example of what an incident form should look like and provides samples of the essential information you should include in any incident-related report. After an injury or illness occurs, this document should be filled out immediately by the injured employee and reviewed by a supervisor as soon as possible.

Downloaded 8 times

Rated 5/5 stars on Capterra

Say goodbye to paper checklists!

Lumiform enables you to conduct digital inspections via app easier than ever before
  • Cut inspection time by 50%
  • Uncover more issues and solve them 4x faster
  • Select from over 5,000 expert-proofed templates

Digitalize this paper form now

Register for free on and conduct inspections via our mobile app

  • Cut inspection time by 50%
  • Uncover more issues and solve them 4x faster
  • Select from over 4000 expert-proofed templates
Rated 5/5 stars on Capterra

Employee Incident Report


Employee Statement

How did you get hurt?
Employee Name
Phone number
Date of birth
Date and Time of Incident
Onset of Illness
Where did the incident happen?
Was someone notified of the injury?
Who was notified?
Date and Time notified
What happened and how did it happen?
If you feel any of the symptoms, list the areas of the body where you feel them and indicate which type of symptom. (click "Add Body Part")
Specify body part
Scale of pain
Take / upload a photo of the body part
Provide details
Was the employee the one who filled out this form?
Do you want medical treatment right now?
Authorization for Release of Medical Information: I hereby authorize any and all providers of medical or surgical treatment deemed necessary in regard to my reported occupational injury or illness to release any medical information acquired in the course of my treatment
Employee's Signature
Name and Signature of Authorized Person
As told to me by (Name of Injured Employee)
Reason why injured worker could not complete this form:
Share this template:

Similar templates