Employee Incident Report Template

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Employee Incident Report Template

An employee incident report documents a workplace issue, event, or injury 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 supervising manager or the company’s HR department for internal review and storage.

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Last updated August 21st, 2025

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An employee incident report documents a workplace issue, event, or injury 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 supervising manager or the company’s HR department for internal review and storage.

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When to Use

  • Accidents, injuries, and near misses
  • Illnesses and medical emergencies
  • Arguments and altercations
  • Poor performance or reprehensible behavior that merits a warning
  • Being inebriated on the job
  • Illegal activity and calls to the police

Sample

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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]