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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.
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Employee Incident Report

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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