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Employee Incident Report Form Template

Streamline workplace safety reporting with our form template

Accidents can happen at any time, and timely reporting is essential for preventing future incidents. This Employee Incident Report Form Template helps you quickly document any unsafe conditions or accidents in the workplace, ensuring that issues are addressed promptly. With clear fields for details like the nature of the incident, affected parties, and immediate actions taken, you can enhance safety protocols, maintain accurate records, and foster a culture of transparency. Plus, it's designed for easy completion and offers WCAG-aligned labels for accessibility. Start improving your incident reporting today!

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Your full name
Job title
Department or team
Employee ID (if applicable)
Phone number
Work email
If 'Other', please specify
Your relationship to the incident
Injured employee
Supervisor or manager
Witness
Safety officer
HR
Contractor
Visitor
Prefer not to say
Other
Please Specify:
Date of incident
Approximate time of incident (HH:MM, include AM/PM)
Exact location of incident (area, room, site)
Location type
On-site - main facility
On-site - field location
Off-site - client location
Remote work
Parking area
Public roadway
During commute
Not sure
Other
Please Specify:
Did this occur on employer property?
Yes
No
Unknown
Brief description of what happened
Incident type (select all that apply)
Please Specify:
Was anyone injured or made ill?
Yes
No
Unknown
Name of injured person (if any)
Role of injured person
Employee
Contractor
Visitor
Client
Vendor
Not applicable
Other
Please Specify:
Nature of injury or illness (select all that apply)
Please Specify:
Body part(s) affected
Please Specify:
Initial severity assessment
No injury or damage
First aid only
Medical treatment required
Lost time from work
Fatality
Unknown
Not applicable
Was medical treatment required?
Yes
No
Unknown
Not applicable
Was the person transported off-site by ambulance?
Yes
No
Unknown
Not applicable
Were there witnesses?
Yes
No
Unknown
Witness names and contact details
May we contact the witness(es)?
Yes
No
Unknown
Not applicable
Contributing factors (select all that apply)
Please Specify:
Immediate cause
Unsafe act
Unsafe condition
Both
Unknown
Not applicable
Were controls or procedures in place at the time?
Yes
No
Unknown
Was personal protective equipment (PPE) worn?
Yes
No
Unknown
Not applicable
PPE involved (select all that apply)
Please Specify:
Equipment name or ID (if applicable)
Was equipment involved?
Yes
No
Unknown
Not applicable
Was first aid provided?
Yes
No
Unknown
Not applicable
Name and role of person providing first aid (if any)
Treatment type
None
First aid on site
Medical treatment off site
Emergency room
Hospitalized
Unknown
Not applicable
Was work stopped in the affected area?
Yes
No
Unknown
Not applicable
Was the area secured or isolated?
Yes
No
Unknown
Not applicable
Was equipment tagged out or locked out?
Yes
No
Unknown
Not applicable
Immediate actions taken to make the area safe
Additional corrective or preventive actions recommended
Where are supporting files stored or how can they be accessed?
Are photos or documents available?
Yes
No
Will provide later
Not applicable
Was a supervisor or manager notified?
Yes
No
Unknown
Date supervisor was notified
Time supervisor was notified (HH:MM, include AM/PM)
Reference numbers or case IDs (if any)
External notifications required or completed (select all that apply)
None
Regulator (e.g., OSHA)
Law enforcement
Client
Insurance
Union representative
Family or emergency contact
Unknown
Other
Please Specify:
Type your full name as signature
Date signed
I affirm that the information provided is accurate to the best of my knowledge.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
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Paper art illustration representing an employee incident report form template for FormCreatorAI article

When to use this form

Use this form whenever a staff member is injured, threatened, or involved in unsafe behavior at work. It helps you and your safety team record facts fast so you can fix hazards, meet policy, and support claims. Typical cases include slips on wet floors, cuts from tools, chemical splashes, equipment failures, bullying, or near-misses. If the issue involves theft or missing property, route details to the Theft report form. For severe events that require escalation or external notification, pair your record with the Critical incident report form. When medical treatment or time off is involved, the Employee accident/incident report form can capture clinical details. Clear, timely reports lead to corrective actions and fewer repeat incidents.

Must Ask Employee Incident Report Questions

  1. What is the date, time, and exact location?

    Time and place anchor the event and let you pull camera footage or access logs. Clear specifics also speed safety reviews and compliance reporting.

  2. What exactly happened, in your own words?

    A first-person, factual summary reduces bias and hearsay. It helps investigators verify the sequence and the conditions that led to the event.

  3. Who was involved and who witnessed it?

    Listing everyone involved and witnesses guides interviews and statements. It also clarifies roles, potential conflicts, and needed notifications.

  4. Were there any injuries, property damage, or near-misses?

    Stating harm, damage, or a near-miss gauges severity and urgency. It triggers the right controls, from first aid to equipment lockout.

  5. What immediate actions were taken and what follow-up is needed?

    Knowing what you did right away shows duty of care and prevents repeat harm. Document remaining tasks and owners so you can complete a clean handoff with the Case closure form.

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