Workplace Incident Report Form

• Incident Numer

• Date & Time of Incident

  Date

• Reported By

• Location
  Address

Victim

• Name

• Job Title

• Store/Department

• Work Address
  Address

• Gender

  Male

  Female

• Contact Number/Email

Alleged Offender(s)

• Do you know the person(s) responsible?

  Yes

  No

  N/A

• Specify Name(s)

• Approximate age

• Gender

  Male

  Female

• Relationship to the victim/reporting employee

  Select Co-worker Customer Supervisor Spouse/Partner Stranger Other

  • Co-worker
  • Customer
  • Supervisor
  • Spouse/Partner
  • Stranger
  • Other

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

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

  Media

• Date reported to regulatory authority

  Date

Completion

• Observations and comments

• Name & signature of person reporting

  Sign