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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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