Workplace Incident Report Form

• Site conducted

  Select

• Date & Time of Incident

  Date

• Reported By

Victim

• Name

• Job Title

• Gender

  Male

  Female

• Contact Number/Email

Alleged Offender(s)

• Do you know the person(s) responsible?

  Yes

  No

• Specify Name(s)

• Approximate age

• Gender

  Male

  Female

• Relationship to the victim/reporting employee

  Co-worker

  Supervisor

  Spouse/Partner

  Other

Details of the Incident

• Type of Incident

  Select Injury/Illness Property Damage Near Miss Hazard Risk Other

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

• What is the nature of the incident?

• Description of Incident

• Description of any injury, illness, property damage, or contributing factors

• Take/ upload photo evidence of incident, environment, person(s) involved

  Media

• Did you report this to your supervisor?

  Yes

  No

• Which supervisor?

• When did you report

  Date

• Were there any witnesses?

  Yes

  No

• Who is the witness?

Completion

• Observations and comments

• Name & signature of person reporting

  Sign