Employee Incident Report Form +Best App for Safety Managers

The Employee Incident Report Form is a vital tool for documenting any incidents involving employees in the workplace.

This form helps capture all relevant details about the incident, facilitating a thorough investigation and appropriate response.

Proper documentation is essential for ensuring workplace safety, addressing any potential issues, and preventing future occurrences.

Employee Incident Report Form

Date of Incident: __________________
Time of Incident: __________________
Reported By: __________________
Location of Incident: __________________
Date of Report: __________________
Report Number: __________________

Employee Details

Name of Employee Involved: _________________________________

Job Title/Position: _________________________________

Department/Team: _________________________________

Contact Information: _________________________________

Incident Details

Type of Incident (e.g., injury, near miss, property damage): _________________________________

Description of the Incident: ________________________________________________________

Specific Location/Area where the Incident Occurred: ________________________________________

Weather Conditions at Time of Incident (if applicable): _____________________________________

Witness Information

Names of Witnesses: _______________________________________________________________

Contact Information of Witnesses: ___________________________________________________

Injury and Damage Details (if applicable)

Nature of Injuries Sustained: ________________________________________________________

Part of Body Injured: _________________________________

First Aid Provided: Yes / No

Details of First Aid Provided: _____________________________________________________

Medical Treatment Required: Yes / No

Details of Medical Treatment: _____________________________________________________

Description of Property Damage: ____________________________________________________

Estimated Cost of Damage: _________________________________

Cause and Contributing Factors

Immediate Cause of the Incident: ____________________________________________________

Underlying or Contributing Factors: __________________________________________________

Actions Taken

Immediate Actions Taken to Address the Incident: _______________________________________

Corrective Actions Implemented: ____________________________________________________

Preventative Measures to Avoid Recurrence: __________________________________________

Investigation Details

Name of Investigator: _________________________________

Date of Investigation: _________________________________

Summary of Investigation Findings: ___________________________________________________

Additional Observations

Signatures

Report Prepared By: __________________ Signature: __________________ Date: __________________

Supervisor/Manager’s Signature: __________________ Date: __________________

Safety Officer’s Signature (if applicable): __________________ Date: __________________

__________________________________________________________________________________________

The Employee Incident Report Form is crucial for accurately recording the details of any workplace incidents.

It supports a comprehensive investigation, facilitates corrective actions, and helps prevent future incidents.

Regular use of this form enhances workplace safety and ensures compliance with occupational health and safety regulations.

Choose Connecteam, the #1 Choice for Safety Managers

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Take charge with our Forms and Checklists feature, effortlessly running your daily tasks and delivering the highest standards. But that’s just the beginning! 

Easily create perfect employee schedules with our Employee Scheduler, enabling seamless staff organization and maximizing productivity. Keep a tight grip on employee work times using our Time Clock feature, making precise payroll a breeze and freeing you from mundane administrative tasks.

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