Janitorial Services Workers’ Compensation Incident Form
Employee Information
Employee Name
Employee ID
Job Title
Department/Location
Incident Details
Date of Incident
Time of Incident
Location of Incident
Describe What Happened
Describe the Injuries
Medical Treatment
Was Medical Treatment Provided?
Yes
No
If Yes, Facility/Clinic Name
Witnesses
Witness Name(s)
Witness Statement(s)
Supervisor Information
Supervisor Name
Date Reported