Employee Incident Report
 
verisign

Employee Incident Report
Location*  
  location other expalin
Report Number  
Choose One:*
This is an Actual Report
This is a Training Report
Date of Incident:*  
Your Name*  
Other Employees:*   Others on duty?
Call Supervisor?*
Yes
No
If necessary per proper Policy
General Incident Report Information
Description*   Full details/include location
Who Reported the Incident?
Report Number  
Who Reported Incident?*
Employee
Tenant
Other, explain:
  Full details/include location
Space #  
Full Name  
Address Line 1:  
Address Line 2:  
City-State-Zip  
Home Phone:  
Business Phone:  
Cell Phone:  
E-Mail:  
Emergency Services
Report Number  
Was 911 dialed?*
Yes
No
Were Police On-site?*
Yes
No
Was Fire Department On-Site?*
Yes
No
Emergency Medical/Paramedics On-Site?*
Yes
No
Emergency Elevator Service or Rescue?*
Yes
No
Specify Other Services/Details  
Witnesses Information
Report Number  
Witness:*
Employee
Tenant
None
Other, explain:
 
Full Name:  
Address Line 1:  
Address Line 2:  
City-State-Zip  
Home Phone:  
Business Phone:  
Cell Phone:  
E-Mail:  
Injuries Information
Report Number  
Injuried Employee?
Yes
No
Work Related?
Yes
No
Unknown
Injuried Fulled Name:  
Address Line 1:  
Address Line 2:  
City-State-Zip  
Home Phone:  
Business Phone:  
Cell Phone:  
E-Mail:  
Description   Full details/include location
Property Damage Information
Report Number  
Whose Property was involved?*
Company Property
Employee Property
Tenant Property
No Property was involved
Other, explain:
  Full details/include location
Space #  
Full Name:  
Address Line 1:  
Address Line 2:  
City-State-Zip  
Home Phone:  
Business Phone:  
Cell Phone:  
E-Mail:  
Description   Full details/include location
Auto Related Accident/Incident Report Information
Report Number  
Injuried First Name:  
DL #  
DL State  
DL EXP Date  
Vehicle Lic #  
Veh Lic State  
Veh Lic Exp Date   Date of written report
Vehicle Make  
Vehicle Model  
Vehicle Color  
Address Line 1:  
Address Line 2:  
City-State-Zip:  
Home Phone:  
Business Phone:  
Cell Phone:  
E-Mail:  
Description   Full details/include location
Certification and Filing Instructions
I certify that the information that is contained in this report is true and accurate.
Signature:*   fill in your name


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