Fillable Printable Employee Incident Report Form - Texas
Fillable Printable Employee Incident Report Form - Texas
Employee Incident Report Form - Texas
EMPLOYEE INCIDENT REPORT
Name of Employee: _________________________________ Employee Status: Full-Time Part-Time
Title: _____________________________________________ STC A Number: _________________
Address: _________________________________________ City: _______________ State: ______
Zip:_________ Home Phone: _____________________ Cell Phone: ____________________ Work Phone:
_____________________ Date of Birth: __________________ Gender
M F Marital Status: _____
# of Dependents: _______
Date of Injury: ______________ Time of Occurrence: ________________ Date Supervisor Notified: _____________
Supervisor’s Name: ___________________________________ Supervisor’s Phone #: ___________________________
Dept/Location where accident/illness occurred: __________________________ On employer’s premises: Yes No
If NO where: _________________________________________________________________________________________
What was the employee doing just before the incident occurred? Describe the activity, as well as the tools equipment or
material the employee was using. Be specific.
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
What happened? Tell us how the injury occurred.
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
What was the injury/illness? Tell us the part of the body that was affected and how it was affected. Be specific, i.e.
“strained back,” “chemical burn, right hand,” “sprained left ankle”.
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Were safeguards or safety equipment provided? Yes No
Were they used? Yes No
Name of Phone of Witness(es): ___________________________________________________________________________
Initial Treatment:
Record Only Minor By Employee Minor Clinic/Hospital
Emergency Care Hospitalized > 24 hrs Future Major Medical/Lost Time Anticipated
Employee’s Signature: _________________________________________ Date: ______________________________
Supervisor’s Signature: ________________________________________ Date: ______________________________
EMPLOYEE INCIDENT REPORT REVISED 2012-08-10 HS/HR
