Employee Incident Report Form

Time

Location

Name, Department, For others, please specify:

Nature of Incident:

Number of injured/casualties

Nature of injuries, Names of witnesses, Contact information, Immediate actions taken by the employee:, Actions taken by others on the scene:, Response from emergency services:, Possible causes of the incident:, Contributing factors:, What are the recommended measures to consider to prevent similar incidents from happening in the future?

Signature

Date