Templates
Employee incident statement form

Employee incident statement form

Capture detailed employee statements regarding workplace incidents with this form. It provides a structured format for employees to describe events and impacts. Use this form to gather accurate information and support investigations.

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The Lumiform application helps frontline teams uphold internal standards effortlessly.
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  • Assign and track corrective actions
  • Get reports and analyse your data
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Employee incident statement form

Capture detailed employee statements regarding workplace incidents with this form. It provides a structured format for employees to describe events and impacts. Use this form to gather accurate information and support investigations.

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

Document employee perspectives on workplace incidents with this comprehensive statement form. This template helps you collect detailed firsthand accounts from workers involved in or witnessing accidents, injuries, or near-misses. Unlike supervisor-completed incident reports, this form captures the unique viewpoint of employees in their own words essential for thorough investigations and identifying root causes.

According to the National Safety Council, organizations with robust incident reporting systems can reduce their risk of workplace injuries by up to 50%. You can use this template to establish a clear record of events, support workers’ compensation claims, and create documentation that helps prevent similar incidents in the future.

Related categories

Preview of the template
Page 1
Incident Details
Date of Incident
Time of Incident
Describe the Incident
Involved Parties
Names of Involved Parties
Witness Information
Witnesses present?
Reporting Employee Details
Employee Name
Employee ID
Department
Job Title
Signature
Date

Frequently asked questions

How does an employee incident statement form improve workplace safety?

An employee incident statement form improves workplace safety by ensuring detailed and consistent documentation of incidents. This helps identify patterns and root causes, enabling you to implement effective preventive measures. By fostering transparency and accountability, it encourages prompt reporting and proactive safety management.

Are employee incident statement forms legally required after workplace accidents?

Legal requirements vary by jurisdiction and incident severity. OSHA requires documentation of work-related injuries and illnesses, though the specific format isn’t complusory. Employee statements provide valuable documentation that supports required reporting and creates a defensible record if legal or insurance issues arise later.

How can I encourage employees to provide honest incident statements?

Create a blame-free reporting culture by emphasizing that statements are for prevention, not punishment. Clearly communicate that detailed, honest accounts help identify systemic issues rather than assign blame. Ensure confidentiality where appropriate and follow up with employees about preventive measures implemented based on their input.

What should I do if an employee refuses to complete an incident statement form?

First, understand their concerns—they may fear repercussions or be uncomfortable with writing. Offer alternatives like verbal statements that you document, assistance from a neutral third party, or simplified forms. Emphasize that statements help prevent future incidents and aren’t used for disciplinary purposes.

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.