Workplace Incident Reporting Form
Workplace Incident Reporting Form
Complete each section with accuracy and detail, and submit it to the safety department within [24 hours] of the incident.
Employee Information
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Employee's Full Name: |
[Employee's Name] |
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Job Title: |
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Department/Team: |
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Supervisor's Name: |
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Contact Information: |
Incident Details
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Date of Incident: |
[Month Day, Year] |
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Time of Incident: |
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Exact Location of Incident: |
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Description of the Incident: |
Witness Information
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Witness Name(s): |
[Your Name] |
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Contact Information: |
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Witness Account: |
Injury Information
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Nature of Injury: |
Minor head contusion |
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Part of Body Affected: |
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First Aid Administered: |
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Medical Attention Required: |
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Medical Facility Visited: |
Property Damage Information
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Description of Property Damage: |
Minor damage to shelf corner |
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Estimated Cost of Damage: |
Immediate Actions Taken
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List of immediate corrective actions: |
The wet floor was cleaned immediately, and additional caution signs were placed. |
Additional Comments/Statements:
Signature of Reporting Employee:
[Your Name]
[Job Title]
[Month Day, Year]
