Select your state

Your state determines applicable workers' compensation laws and OSHA reporting requirements

Not legal advice. Terms · Privacy · Disclaimer

Document Preview

Employee Incident Report

Report Date:

State:

Severity:

SECTION 1: INCIDENT DETAILS

Date: ________________ Time: ________
Location: ________________________________

Description:
________________________________

Immediate Actions Taken:
________________________________

SECTION 2: EMPLOYMENT & CLAIM STATUS

Department: ________________
Supervisor Name: ________________
Severity: ________________
Workers' Comp Claim: ________
Modified Duty Available: ________

SECTION 3: PEOPLE INVOLVED

SECTION 4: WITNESSES

No witnesses identified.

SECTION 5: ROOT CAUSE ANALYSIS

Root Cause:
________________________________

Corrective Actions Planned:
________________________________

Select your state

Frequently Asked Questions