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Workplace Incident Report Form Template

A workplace incident report form is a tool used by any staff to record incidents that caused injuries within the workplace. Indicate the individuals involved and the injuries sustained. Using this checklist can also document workplace violence and be helpful in compensation, insurance claims, and court cases.

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Workplace Incident Report Form Template

Inspection

Victim

Name
Job Title
Store/Department
Work Address
Gender
Contact Number/Email

Alleged Offender(s)

Do you know the person(s) responsible?
Specify Name(s)
Approximate age
Gender
Relationship to the victim/reporting employee

Details of the Incident

Type of Incident
Description of Incident
Description of any injury, illness or property damage
Take/ upload photo evidence of incident, environment, person(s) involved
Date reported to regulatory authority

Completion

Observations and comments
Name & signature of person reporting
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