Templates
Employee incident report template

Employee incident report template

Document workplace incidents effectively with this comprehensive employee incident report template. It helps capture details and identify causes for corrective actions. Use this template to enhance workplace safety and prevent future incidents.

Use this template with Lumiform

The Lumiform application helps frontline teams uphold internal standards effortlessly.
  • Customize this template or build your own
  • Fill out templates via mobile app
  • Assign and track corrective actions
  • Get reports and analyse your data
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or Download template as PDF
Employee incident report template

Document workplace incidents effectively with this comprehensive employee incident report template. It helps capture details and identify causes for corrective actions. Use this template to enhance workplace safety and prevent future incidents.

Use this template with Lumiform

The Lumiform application helps frontline teams uphold internal standards effortlessly.
  • Customize this template or build your own
  • Fill out templates via mobile app
  • Assign and track corrective actions
  • Get reports and analyse your data
Prices start from ░░░ per month
Book a demo
Learn more
or Download template as PDF

Our Employee Incident Report Template helps you document workplace accidents and injuries with precision and thoroughness. You can quickly record crucial details like incident time, location, involved parties, and also contributing factors all essential for proper investigation and prevention of future occurrences.

When an employee slips on an unmarked wet floor, this template guides you through capturing environmental conditions, witness statements, and immediate actions taken, creating a comprehensive record that supports both compliance and safety improvement. According to the US Bureau of Labor Statistics, approximately 2.7% of workers experience a workplace injury that results in days away from work, making standardized incident documentation an essential risk management tool.

Related categories

Preview of the template
Audit
Employee Statement
How did you get hurt?
Employee Name
Occupation
Address
Phone number
Date of birth
Date and Time of Incident
Onset of Illness
Where did the incident happen?
Was someone notified of the injury?
Who was notified?
Date and Time notified
What happened and how did it happen?
If you feel any of the symptoms, list the areas of the body where you feel them and indicate which type of symptom. (click "Add Body Part")
Specify body part
Symptom
Scale of pain
Take / upload a photo of the body part
Provide details
Was the employee the one who filled out this form?
Do you want medical treatment right now?
Authorization for Release of Medical Information: I hereby authorize any and all providers of medical or surgical treatment deemed necessary in regard to my reported occupational injury or illness to release any medical information acquired in the course of my treatment
Employee's Signature
Name and Signature of Authorized Person
As told to me by (Name of Injured Employee)
Reason why injured worker could not complete this form:
This template was downloaded 8 times

Frequently asked questions

Who should fill out the employee incident report form?

The employee incident report should primarily be completed by the supervisor or manager who witnessed the incident or was first notified. However, the injured employee and any witnesses should also provide input to ensure accuracy. Some organizations have the injured employee complete their section first, followed by supervisor verification.

How can I ensure my employee incident reports are legally sound?

Create legally sound incident reports by sticking to observable facts rather than opinions or blame, documenting all details promptly, including witness statements, preserving evidence through photos or videos, maintaining confidentiality, and following your organization’s reporting procedures. Avoid speculative language about fault or liability in the initial documentation.

What are the benefits of documenting involved parties in an incident report?

Documenting involved parties in an incident report is essential for accountability and follow-up. It ensures that all relevant individuals are informed and involved in the resolution process. This transparency also helps maintain trust within your team and supports a collaborative approach to improving workplace safety.

What happens after I submit an employee incident report?

After submission, your employee incident report triggers an investigation process where safety personnel review details, interview witnesses, analyze root causes, and recommend preventive measures. The report becomes part of your organization’s safety records, you can also use it for workers’ compensation claims, and helps identify patterns that inform future safety training and protocols.

This template, developed by Lumiform employees, serves as a starting point for businesses using the Lumiform platform and is intended as a hypothetical example only. It does not replace professional advice. Companies should consult qualified professionals to assess the suitability and legality of using this template in their specific workplace or jurisdiction. Lumiform is not liable for any errors or omissions in this template or for any actions taken based on its content.