Workplace Incident Report Form

Information you will need

• What time of day did the incident occur?
• Was anyone injured?
• Were the police notified?
• Was a police report filed?
• Who’s filing the report?
• What’s the date of the incident?
• At what time did the incident occur?
• Where did the incident occur?
• What happened?
• What’s the name of the person involved?
• What’s the person’s phone number?
• What’s the person’s email?
• What’s the address of the person involved?
• What’s the name of the second person involved? (if applicable)
• What’s the second person’s phone number?
• What’s the second person’s email?
• What’s the address of the second person involved?
• What’s the name of the third person involved? (if applicable)
• What’s the third person’s phone number?
• What’s the third person’s email?
• What’s the address of the third person involved?
• What’s the name of the fourth person involved? (if applicable)
• What’s the fourth person’s phone number?
• What’s the fourth person’s email?

…and 40 more fields in the PDF.

Completed by the employee.

The form includes 2 signature lines, a witness section.