Workplace Accident Incident Report
Date of Incident:
Time of Incident:
Location of Incident:
Employee(s) Involved:
Job Title(s):
Department:
Description of Incident:
Injury Details (if any):
Witness(es):
Immediate Action Taken:
Reported To:
Date & Time Reported:
Follow-up/Recommendations:
Further Actions Required:
Report Completed By:
Name:
Signature:
Date: