Incident Reporting Form

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Incident Reporting Form

Please use this form to report any workplace accident, injury, incident, conflict, or any similar instance. Please complete thoroughly and accurately.

You will NOT be able to resubmit any information, so please review thoroughly before submitting.

Email *

Person Completing Report *

First and Last Name.

Individual(s) Involved in the Incident

Please list name(s) of the individuals involved in the incident. If you were involved in the incident, please include yourself.

I am documenting a(n): *

Accident

Injury

Incident

Observation

Other:

Date of Incident *

Please indicate when the incident occurred.

YYYY

Approximate Time of Incident *

Please indicate around what time the incident occurred.

Time

Location of Incident *

Please indicate where the incident occurred.

Were there any witnesses? *

Please indicate any witnesses who were present when the incident occurred.

Description of Incident *

Please describe the incident that happened, including the sequence of events and any tasks being performed. If more space is needed, please fill out the next question.

Description of Incident Continued

Please use this space to continue your description of the incident.

What was the cause of the incident? *

Unsafe act (i.e. activity, movement)

Unsafe condition (i.e. equipment, weather)

Confrontation between parties involved

Other:

Was medical treatment necessary? *

If yes, please answer the next question.

Yes

If medical treatment was necessary, which hospital or physician did you go to?

If necessary to disclose, may we share the information you have shared with us?

Yes

Clear selection

By submitting this Leave of Absence Request form, I am acknowledging the following:

+ I have filled this out to the best of my ability, knowledge, and recollection.

+ This form is for documentation and employer/employee records.

+ The information provided will be considered confidential.

+ I understand the information provided here will be considered and will be subject as proof for appropriate action, if any needs to be taken.

I agree.

I disagree.

Clear selection

A copy of your responses will be emailed to the address you provided.

Submit

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