Workplace Incident Report Form

• Date & Time of Incident

  Date

• Reported By

• Location
  Address

Victim

• Name

• Job Title

• Secteur/Département

• Work Address
  Address

• Gender

  Male

  Female

• Contact Number/Email

Alleged Offender(s)

• Do you know the person(s) responsible?

  Yes

  No

  N/A

• Quels sont ses noms et prénoms ?

  Yes

  No

  N/A

• Quel est son numéro de téléphone ?

  Yes

  No

  N/A

• Approximate age

• Gender

  Male

  Female

Details of the Incident

• Type of Incident

  Select Injury/Illness Property Damage Near Hit Hazard Risk Other

  • Injury/Illness
  • Property Damage
  • Near Hit
  • Hazard
  • Risk
  • Other

• Description of Incident

• Description of any injury, illness or property damage

• Date reported to regulatory authority

  Date

Completion

• Observations and comments

• Name & signature of person reporting

  Sign