Workplace Accident Incident Report
General Information
Date of Incident
Time of Incident
Location of Incident
Department
Personal Information
Full Name of Injured Person
Job Title
Contact Information
Incident Details
Description of Incident
Type of Injury
Body Part Affected
Immediate Action Taken
Witness Information
Name(s) of Witness(es)
Witness Statement(s)
Reporter Information
Reported By
Date Reported