Inspection

Victim

Name

Job Title

Store/Department

Work Address

Gender

Contact Number/Email

Alleged Offender(s)

Do you know the person(s) responsible?

Specify Name(s)

Approximate age

Gender

Relationship to the victim/reporting employee
Details of the Incident
Type of Incident

Description of Incident

Description of any injury, illness or property damage

Take/ upload photo evidence of incident, environment, person(s) involved
Date reported to regulatory authority
Completion

Observations and comments

Name & signature of person reporting
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.