Employee Incident Report

Parklane Employee Report

Note: At the time of printing, this form had not been submitted.

Introduction

Employee Details

Employee Name:

Reporting Information

Supervisor


Please provide your contact information below

Your Telephone Number:

Your Email Address:

Incident Description

Incident Type





Date of Incident
Time

Incident Details

Witness(es) of Incident

Location where incident occurred


What were you doing at the time of this incident?
(ex. cutting open a box, pushing cart, etc., provide more detail)

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What happened to cause this incident?
(Contributing factors related to people, process, equipment, materials, and environment)

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Provide all additional details that are relevant or significant.
Examples:
-Description and weight being lifted or moved (kg or lbs)
-How long was the task being performed on the day of the injury?
-How long was the task performed in the last hour leading up to the reported injury?
-Was there a specific incident to cause the injury?


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