Employee Incident Report Template
Accidents and injuries can occur in any workplace, and it's essential to have a structured process for reporting and documenting such incidents. Our Employee Incident Report Template provides a comprehensive framework for recording crucial details when an employee experiences an incident or injury while on the job.
Here's a breakdown of what each section entails:
Employee Information: This section records essential details about the employee involved, such as their name, date of birth, Social Security Number, contact information, job title, and the name of their manager.
Incident Information: Here, you'll find information about the incident itself, including the date and time of the incident, the location where it occurred, and whether a supervisor or manager was notified. A brief description of the incident is also provided.
Injuries Reported: This part documents any injuries sustained during the incident, specifying the affected body part. It also allows for the option to indicate if there were no injuries or if the information is not applicable.
Employee(s) Involved: Records the names of employees involved in the incident and whether there were any witnesses or property damage.
Medical Treatment: Documents whether medical treatment was provided, including the medical facility's name, if applicable.
Worker's Compensation and Other Information: This section focuses on worker's compensation details, including whether the injury was reported to the company's workers' compensation carrier, the compensation type, total compensation amount, payment method, and any additional compensation notes. It also covers follow-up medical care and the return-to-work plan.
Incident Report Prevention and Signatures: This part highlights actions taken to prevent a recurrence of the incident, such as implementing safety measures. It includes areas for the preparer's and reviewer's signatures, as well as space for the employee's signature and additional comments.
