Employee Incident Report Template

REPORTED BY:	DATE OF REPORT:
TITLE / ROLE:	INCIDENT NO.:

EMPLOYEE INCIDENT INFORMATION
EMPLOYEE NAME:	EMPLOYEE TITLE / ROLE:
DATE OF INCIDENT:	TIME OF INCIDENT:
LOCATION:
SPECIFIC AREA OF LOCATION:
ADDITIONAL PERSON(S) INVOLVED:
WITNESSES:
INCIDENT DESCRIPTION INCLUDING ANY EVENTS LEADING TO OR IMMEDIATELY FOLLOWING THE INCIDENT:
EMPLOYEE EXPLANATION OF EVENTS / CIRCUMSTANCES:
RESULTING ACTION EXECUTED, PLANNED, OR RECOMMENDED:

EMPLOYEE NAME:	EMPLOYEE SIGNATURE:	DATE:
REPORTING STAFF NAME:	REPORTING STAFF SIGNATURE:	DATE:
HR REP NAME:	HR REP SIGNATURE:	DATE:

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