Incident Information

Incident Description

Incident Photo(s)

Employee Information

Employee/Witness Data


Involved Employee or Witness?

Employee Name:

Employee ID#:

Job Title:

Length of Employment:


Number of Days Worked Concurrently:

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.