Employee Incident Form

Use this form to report accidents, injuries, medical situations, criminal activities, traffic incidents, or student behavior incidents. If possible, a report should be completed within 24 hours of the event.

Date of Report *

Person Involved

Employee Full Name *

Employee ID *

Employee Email *

Employee Phone Number *

Employee Address *

The Incident

Date of Incident *

Time of Incident *

Location of Incident *

Describe the Incident *

Injuries

Was Anyone Injured? *

Name(s) of Person(s) Injured

If Yes, Describe the Injuries

Witnesses

Were There Witnesses to the Incident? *

If Yes, Please Provide Witnesses Names and Contact Info

Police & Medical Services

Were the Police Notified? *

If Yes, Was a Report Filed?

Police Case Number if Applicable

Was Medical Treatment Provided? *

If Yes, Where Was the Medical Treatment Provided *

Person Filing Report

Full Name *

Reporter Signature *

Clear