Public Transportation Workers’ Compensation Incident Report
Employee Information
Full Name
Employee ID
Department/Position
Phone Number
Incident Details
Date of Incident
Time of Incident
Location
Describe what happened
Witness(es)
Equipment/Vehicle involved
Injury Information
Nature of Injury
Part(s) of body affected
Severity (if known)
Medical Attention Required?
Yes
No
Treatment Administered / Hospital or Clinic Name
Other Details
Immediate Actions Taken
Supervisor Notified (Name)
Date/Time Supervisor Notified
Reporting Employee
Name
Signature
Date