Employee Incident Report Form

An Employee Incident Report Form is a crucial document used to record workplace incidents, including accidents, injuries, illnesses, or any other event that may impact the safety, health, or well-being of employees. The form helps to ensure that incidents are documented, analyzed, and addressed appropriately to prevent future occurrences. Below are guidelines for creating an Employee Incident Report Form:
1. Header Information
Date of Report: Include the date when the report is being filed.
2. Employee Information
Full Name: The name of the employee involved in the incident.
Job Title: Employee’s position within the company.
Employee ID (if applicable): A unique identifier for the employee.
Contact Information: Phone number and email address for further communication.
3. Incident Details
Date and Time of Incident: When the incident occurred.
Location of Incident: Specific place (e.g., office, warehouse, parking lot) where the incident took place.
Description of Incident: A detailed account of what happened. The description should include:
5. Injury/Illness Details (if applicable)
Type of Injury/Illness: Specific injury or illness sustained, e.g., sprain, burn, or chemical exposure.
Body Part Affected: The body part(s) involved (e.g., hand, back, head).
Severity: Description of the severity of the injury, such as minor, moderate, or severe.
Treatment Provided: Any first aid or medical treatment administered.
Medical Care: Whether the employee required further medical care (e.g., doctor visit, hospitalization) or was released after treatment.
6. Root Cause Analysis (optional but recommended)
Cause(s) of the Incident: Identify potential root causes of the incident, such as human error, equipment malfunction, or unsafe working conditions.
Contributing Factors: Include any factors that might have contributed to the incident, such as inadequate training, fatigue, or lack of safety equipment.
7. Corrective Actions and Follow-Up
Immediate Actions Taken: Any steps that were immediately taken to remedy the situation (e.g., closing off the area, issuing safety instructions).
Long-Term Actions: Suggested or planned corrective actions to prevent future incidents, such as additional training, policy changes, or safety equipment upgrades.
Follow-Up Date: Date when follow-up will occur to assess the effectiveness of corrective actions.
8. Signature Section
Employee Signature: The employee involved in the incident signs to confirm the accuracy of the report.
Supervisor Signature: The supervisor reviews the report, signs, and confirms the incident has been documented.
Date: Date when the report was signed.
9. Confidentiality Statement
Include a statement that the report will be kept confidential and only shared with relevant parties for safety or legal purposes.