Employee Incident Report Template

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Employee Incident Report Template

An employee incident report documents an issue that occurs concerning an employee. It describes the incident, including the date, time, and location, and the parties involved. The completed document should be given to a superior manager or the company’s HR department.

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Last updated August 8th, 2025

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An employee incident report documents an issue that occurs concerning an employee. It describes the incident, including the date, time, and location, and the parties involved. The completed document should be given to a superior manager or the company’s HR department.

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When to Use

  • Accidents, injuries, and near misses
  • Illnesses and medical emergencies
  • Arguments and altercations
  • Missing work
  • Being inebriated on the job
  • Illegal activity and calls to the police

Sample

Download: PDF, MS Word, ODT

EMPLOYEE INCIDENT REPORT FORM
INDIVIDUAL FILING REPORT

Full Name: [FULL NAME] Title/Role: [TITLE/ROLE]
Signature:                                                           Date: [MM/DD/YYYY]

INCIDENT DETAILS
Date of Incident: [DATE OF INCIDENT]      Time: [TIME] ☐ AM ☐ PM Location: [LOCATION]

Describe the Incident: [DESCRIBE THE INCIDENT]

PARTIES INVOLVED
Full Name: [FULL NAME] Phone: [PHONE] E-Mail: [EMAIL] Address: [ADDRESS]
Identification: ☐ Driver’s License No. [DL NUMBER] ☐ Passport No. [PASSPORT NUMBER] ☐ Other: [OTHER]

Full Name: [FULL NAME] Phone: [PHONE] E-Mail: [EMAIL] Address: [ADDRESS]
Identification: ☐ Driver’s License No. [DL NUMBER] ☐ Passport No. [PASSPORT NUMBER] ☐ Other: [OTHER]

INJURIES
Was anyone injured? ☐ Yes ☐ No If yes, describe the injuries: [INJURY DESCRIPTION]

WITNESSES
Were there witnesses to the incident? ☐ Yes ☐ No

If yes, enter the witnesses’ names and contact info:

  1. Full Name: [FULL NAME] Phone: [PHONE] E-Mail: [EMAIL]
  2. Full Name: [FULL NAME] Phone: [PHONE] E-Mail: [EMAIL]

POLICE/MEDICAL SERVICES
Police Notified?☐ Yes ☐ No

If yes, was a report filed? ☐ Yes ☐ No

Was medical treatment provided? ☐ Yes ☐ No ☐ Refused

If yes, where was medical treatment provided? ☐ On site ☐ Hospital ☐ Other: [OTHER]