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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

Workplace Incident Report Form Checklist

Created by: SafetyCulture Staff | Industry: General | Downloads: 241

A workplace incident report form is a tool used by any staff to record incidents that caused injuries within the workplace. Indicate the individuals involved and the injuries sustained. Using this checklist can also document workplace violence and be helpful in compensation, insurance claims, and court cases.

Signup for a free iAuditor account to download and edit this checklist. It will be added to your free account and you will be able to conduct inspections from your mobile device.

Download and edit this free checklist

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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