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Employee Incident Report Form

An incident report form was submitted to document an event. The form collected information about the incident such as date, location, names of those involved, and their roles. A description of what happened and factors leading to the incident was requested. Space was provided to note any witnesses and contact information. The individual submitting the report was asked to print and sign their name along with the date. A section for office use only was included to document any follow-up actions taken in response to receiving the incident report.

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Agnes Carbonell Cabacungan
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137 views2 pages

Employee Incident Report Form

An incident report form was submitted to document an event. The form collected information about the incident such as date, location, names of those involved, and their roles. A description of what happened and factors leading to the incident was requested. Space was provided to note any witnesses and contact information. The individual submitting the report was asked to print and sign their name along with the date. A section for office use only was included to document any follow-up actions taken in response to receiving the incident report.

Uploaded by

Agnes Carbonell Cabacungan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Incident Report No.

2018 - 06 - _________
Please use this form to report accidents, injuries, medical situations, or employee conduct / behavior incidents. If
possible, this report should be completed and submitted within 24 hours of the happening of the incident /
accident. Submit completed forms to the Division Head and / or HR Manager cc: Office of the COO. You can also
send a scanned copy thru e-mail. This form may be accomplished in English or Tagalog.

A. INFORMATION ABOUT THE INCIDENT


Full Name : 1. ___________________________________________________

2. ___________________________________________________

Position : 1. ___________________________________________________

2. ___________________________________________________

Please check:

Employee : ______ Vehicle : _______ ( Plate No. __________________ )


Visitor : ______ Damage to Company or Public Property : _______
Vendor / 3rd Party : ______ Loss of Company Property : _______
Violation of Company Code of Conduct : _______

Date of Incident : __________________________________ Time Police Notified Yes No

Place of Incident : __________________________________

B. DESCRIPTION OF INCIDENT : (WHAT happened, HOW it happened, factors leading to the event, etc.)
Be as specific as possible. Attached additional sheets if necessary.

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Were there any witness/es to the incident? Yes No

If yes;

Names : _______________________________________

Addresses: _____________________________________

Contact phone numbers: __________________________

C. REPORTED BY:

Individual Submitting Report (print name): _____________________________________

Signature : _______________________________________________________________

Date Report Completed: ____________________________________________________

D. FOR OFFICE USE ONLY

Document any follow-up action taken after receipt of the incident report.

Date By Whom Action Taken Remarks

adb05312018/

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