top of page
INCIDENT REPORT FORM

1. GENERAL INFORMATION

2. PERSON(S) INVOLVED

3. INCIDENT DETAILS

Type of Incident (Check all that apply)
Was there any equipment or machinery involved?
Were there any hazardous conditions (e.g., wet floors, faulty equipment)?

4. WITNESS INFORMATION

Were there any witnesses?

5. INJURY DETAILS (If applicable)

Did the employee seek medical attention?
Was medical leave required?

Thank you for your report.

bottom of page