Workplace Incident Report Form Template

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Workplace Incident Report Form Template

Inspection

Victim

Name

Job Title

Store/Department

Work Address

Gender

Male Female

Contact Number/Email

Alleged Offender(s)

Do you know the person(s) responsible?

Yes No N/A

Specify Name(s)

Approximate age

Gender

Male Female

Relationship to the victim/reporting employee

Select Co-worker Customer Supervisor Spouse/Partner Stranger Other

Details of the Incident

Type of Incident

Select Co-worker Customer Supervisor Spouse/Partner Stranger Other

Description of Incident

Description of any injury, illness or property damage

Take/ upload photo evidence of incident, environment, person(s) involved

Add Photo

Date reported to regulatory authority

Select date

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.