Employee Incident Report

Use this form to report accidents, injuries, medical situtations, criminal activities, traffic incidents that are not reportable to worker's compensation. If possible, a report should be completed within 24 hours of the event.

1. PERSON INVOLVED

Full Name:

required

Address:

required

Identification Type:

required

Driver's License No.

Passport No.

Other

Identification Number:

required

Phone

required

2. THE INCIDENT

Date of Incident:

required

Time:

required

Location:

required

Describe the Incident:

required

3. INJURIES

Was anyone injured?

required

Yes

Describe the injuries:

required

4. WITNESSES

Aside from yourself, were there other witnesses to the incident?

required

Yes

Please enter witnesses' names and contact info:

required

5. POLICE / MEDICAL SERVICES

Police Notified?

required

Yes

Was a police report filed?

required

Yes

Was medical treatment provided?

required

Yes

Refused

Where was medical treatment provided?

required

On site

Hospital

Other

6. PERSON FILING REPORT

Signature:

required

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