Employee Incident Reports

EMPLOYEE INCIDENT REPORT

Report Information

Report ID:    Date of Report:

Employee Information

Phone:    Email:

Position Information

Reporting Manager:    Hire Date:

Incident Details

Date of Incident:    Time of Incident:

Injury Sustained: Yes No    Transported for Medical Treatment: Yes No

Witnesses

Property / Equipment Damage

Damage Sustained: Yes No

Incident Classification

Near Miss    First Aid    Medical Treatment    OSHA Recordable

Investigation & Corrective Action

Action Responsible:    Due Date:

Attachments

Photos    Medical Report    Witness Statements    Other

Employment History

Provide two most recent prior employers as required by company personnel records.

Education

References

Provide three professional references.

Legal Disclosures & Company Policies

At-Will Employment Statement: Employment remains at-will where applicable. Nothing in this report or the act of submitting this report alters the at-will employment relationship or creates a contract of employment for any specified duration.

Equal Opportunity Statement: The company prohibits unlawful discrimination and will investigate incidents consistent with applicable law and company policy. All reports will be handled without unlawful discrimination.

Confidentiality & Non-Retaliation: Information provided in this report will be used for investigation and corrective action. The company prohibits retaliation against any individual who reports an incident in good faith. Deliberately false statements may result in disciplinary action.

Applicant Certification & Authorizations

I certify that all information provided in this incident report is true, complete, and accurate to the best of my knowledge. I understand that submission of inaccurate or misleading information may subject me to disciplinary action. I authorize the company to investigate the facts alleged herein, to review relevant records, and to contact witnesses and prior employers as necessary to verify information related to this incident.

Authorization for Background/Reference Checks: I authorize the company to conduct background and reference checks if deemed necessary as part of the incident investigation.

Acknowledgment

By signing below, the undersigned acknowledge that they have read this report and that the information provided above is accurate to the best of their knowledge. Signing does not necessarily indicate agreement with all conclusions of any subsequent investigation.

Sign Now