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Employee Incident Report

  1. provide all details, including the type of work activity in process, specific incident details, and any contributing factors

  2. Injury/Illness Detail

  3. Be specific (left, right, upper, lower, etc)

  4. (i.e. cut, bruise, strain, etc)

  5. Was Treatment Received for Injury?

  6. Property Damage Detail

  7. NOTE: for vehicles, list year, make & VIN

  8. Attach any documents, photos, law enforcement reports, or other related documents

  9. Leave This Blank: