Sample Employee Incident Reports

We have sample Employee Incident Reports available free to download, customize and print for your small business.

What is an incident form/report? If you are a healthcare facility such as a hospital, nursing home, or assisted living you would use this form to record details of an unusual event that occurs at the facility such as an injury to a patient in the facility.

The purpose of this report for employee incidents or accidents is to document the exact details of the occurrence while they are fresh in the minds of those who witnessed the event. The information in your report might prove to be useful in the future if issues arise from the incident that might cause liability issues with your company.

To maintain a safe and healthy campus/work environment, a thorough accident investigation should be undertaken as soon as practical after an accident or incident in order to initiate and support corrective and/or preventive actions.

The Accident/Incident Report and Investigation Form should be completed by the employee’s supervisor with the employee. The report requires the signature of the supervisor and employee. For accidents or incidents which require medical attention, or lost or restricted work, the report must be signed by the CEO or president of company. Completed reports are to be sent to the Director of Human Resources.

There are three different reports below to choose from or you might want to download all three and take parts from each one to create a perfect report for your company.

The Accident/Incident Report and Investigation Form (6 Pages) includes:

  • Employee Information (Name, Social Security #, Dept., Job Title, Work Status)
  • Accident/Incident Information (Date of Incident, Location, Time, Time Employee Began Work, Type of Incident, and Questions related to Incident such as “What was the injury/illness?”, etc.)
  • Accident/Incident Investigation (Root causes and contribution factors and corrective actions with target completion date.)
  • Employee/Injured Party Signature and Date
  • Supervisor’s Signature and Date
  • CEO/President’s Signature and Date
  • Internal Use Box for Director of Human Resources Signature and Date and Manager of Risk Management Signature and Date
  • Analysis Checklist (Potential causes  such as Mechanical Controls, Design/Construction, Inspection Program/Defective Equipment, Policy/Procedure/Work Instructions, Environmental/Storage Factors, Materials Handling/Process Operations/Maintenance, Similar Accidents/Work Practices/Conditions, Training, Human Factor/Behavior and Supervision where you can check all that apply.)

Click on the link to download the sample Employee Report Form(s) below for Incidents:

 

Incident/Accident Report Investigation Form

Incident/Accident Report Investigation Form

Incident/Accident Report Form

Incident/Accident Report Form

Employee Accident Report Form

Sample Employee Accident Report Form

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