Workplace Incident Report Template

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A workplace incident report captures an employee’s account of an event involving themselves or someone else at work. It’s usually completed after an accident to detail what occurred, who was injured, and any medical treatment provided. This information helps address safety concerns and ensure staff receive proper support (e.g., workers’ compensation) or disciplinary action.

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Workplace Incident Report Template

Last updated September 4th, 2025

A workplace incident report captures an employee’s account of an event involving themselves or someone else at work. It’s usually completed after an accident to detail what occurred, who was injured, and any medical treatment provided. This information helps address safety concerns and ensure staff receive proper support (e.g., workers’ compensation) or disciplinary action.

Federal Reporting Requirements

The Occupational Safety and Health Administration (OSHA) requires employers to notify it of certain workplace incidents within specific timeframes[1]:

  • Fatalities must be reported within 8 hours.
  • Hospitalizations, amputations, or loss of an eye must be reported within 24 hours.

Reports can be filed in person, online, or by phone at 1-800-321-6742.

OSHA Recordkeeping

Employers in specific industries who have 11 or more employees must complete OSHA Form 300A, 300, and 301 within seven days of a serious workplace injury or illness (see general recording criteria for reportable incidents).[2]

Important: Employers must submit all OSHA-required incident data annually through the Injury Tracking Application and retain all OSHA forms for five years.[3]

Sample

Download: PDF, MS Word, ODT

WORKPLACE INCIDENT REPORT FORM

EMPLOYEE INFORMATION

Employee Name: [EMPLOYEE NAME] Job Title: [JOB TITLE]

Supervisor Name: [SUPERVISOR NAME]

Signature:                                                               Date: [MM/DD/YYYY]

INCIDENT DETAILS

Date of Incident: [MM/DD/YYYY] Time: [TIME] ☐ AM ☐ PM

Location: [INCIDENT LOCATION]

Incident Type: ☐ Injury ☐ Illness ☐ Near Miss ☐ Fire ☐ Equipment / Property Damage
☐ Violence ☐ Harassment ☐ Improper Safety Procedures ☐ Other: [OTHER]

Describe the Incident: [DESCRIBE INCIDENT]

Describe what could have been done to prevent the incident: [DESCRIBE MEASURES]

Has the employee’s supervisor been notified about the incident? ☐ Yes ☐ No

PARTIES INVOLVED

    1. Full Name: [FULL NAME] Phone: [PHONE] E-Mail: [E-MAIL]
      Address: [ADDRESS]
    2. Full Name: [FULL NAME] Phone: [PHONE] E-Mail: [E-MAIL]
      Address: [ADDRESS]
    3. Full Name: [FULL NAME] Phone: [PHONE] E-Mail: [E-MAIL]
      Address: [ADDRESS]
    4. Full Name: [FULL NAME] Phone: [PHONE] E-Mail: [E-MAIL]
      Address: [ADDRESS]

INJURIES

Was anyone injured? ☐ Yes ☐ No
If yes, describe: [DESCRIBE INJURIES]

If the employee was injured, did they see a doctor? ☐ Yes ☐ No
If yes, complete the following:

  1. Doctor / Hospital Name: [DOCTOR / HOSPITAL NAME]
  2. Doctor / Hospital Phone: [DOCTOR / HOSPITAL PHONE]
  3. Date of Visit: [DATE]
  4. Time of Visit: [TIME] ☐ AM ☐ PM
  5. Has this part of the employee’s body been injured before? ☐ Yes ☐ No
    • If yes, when? [DATE]

WITNESSES

Were there witnesses to the incident? ☐ Yes ☐ No
If yes, enter the witnesses’ names and contact info:

  1. Full Name: [NAME] Phone: [PHONE] E-Mail: [E-MAIL]
  2. Full Name: [NAME] Phone: [PHONE] E-Mail: [E-MAIL]
  3. Full Name: [NAME] Phone: [PHONE] E-Mail: [E-MAIL]

POLICE / EMERGENCY MEDICAL SERVICES

Police Notified? ☐ Yes ☐ No | If yes, was a report filed? ☐ Yes ☐ No

Was emergency medical treatment provided? ☐ Yes ☐ No ☐ Refused
If yes, where? ☐ On site ☐ Hospital ☐ Other: [OTHER]

Sources

  1. OSHA – Report a Fatality or Severe Injury
  2. 29 CFR § 1904.29(b)(3)
  3. OSHA – Injury and Illness Recordkeeping and Reporting Requirements, 29 CFR 1904.33(a)