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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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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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Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.
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