Templates
Employee incident report template

Employee incident report template

Discover how to effectively document workplace incidents with our employee incident report template. Learn the key elements, benefits, and step-by-step usage to enhance your incident management process and ensure workplace safety.

Use this template
or download pdf
Employee incident report template

Discover how to effectively document workplace incidents with our employee incident report template. Learn the key elements, benefits, and step-by-step usage to enhance your incident management process and ensure workplace safety.

Use this template
or download pdf

About the Employee incident report template

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.

Categories

  • Workforce management and HR templates
Preview of the template
Audit
Employee Statement
How did you get hurt?
Employee Name
Occupation
Address
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
Symptom
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:
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This template, developed by Lumiform employees, serves as a starting point for businesses using the Lumiform platform and is intended as a hypothetical example only. It does not replace professional advice. Companies should consult qualified professionals to assess the suitability and legality of using this template in their specific workplace or jurisdiction. Lumiform is not liable for any errors or omissions in this template or for any actions taken based on its content.