anuary 2015
NORTH CAROLINA EMPLOYEE INCIDENT REPORT
Instructions:
Employee
must complete repor
.
If more room is needed,
continue in a Word document and attach it to this submission.
Employees are required to complete this form for all incidents and near hits. This form should be completed in its entirety and should be an accurate and truthful
account of the accident/incident. Providing false and/or misleading information may result in disciplinary action up to or including dismissal and/or additional
criminal and/or civil liability. This form should be completed by the employee only.
Supervisor Review: If an employee is unable to complete this form, the Supervisor must list reason(s) for assisting or completing this report.
My signature below certifies that the information I have provided is true and accurate. I further understand that this information may be used to determine whether
the claim will be paid or denied and that I should not complete this form unless there are exceptional circumstances present preventing the employee from
completing this form. Check Not applicable (employee completed form) or sign below if you assisted with the completion of this form.
Supervisor Name: Signature:
Employee Information Date/Location Information
Name (Full): Date of Incident: / / Time of Day:
Employee ID #:
Date Reported to
Supervisor: / / Time of Day:
Job Title:
Male
Female
Work Address:
Telephone #:
Department:
Incident Location (address, Building name, office, cross streets, fire
name, woods, facility, room #, etc.):
Agency/University:
Supervisor: Phone #:
Date Hired: Time in Current Job: County:
Witness Information
Were there any witnesses to the incident? Yes No Number of Witnesses (if applicable):
If yes, list all known witnesses/phone #’s below, please include additional names on attachment if needed.
Name: Phone #:
Name: Phone #:
Medical
Information
Part(s) of the body injured:
Prior to this accident/incident, have you ever been hurt, suffered injury, or received treatment for the body part(s) listed above? Yes No
If yes, please provide the date of prior injury, type of injury, names of treating physician or practice group.
Description of Accident/Incident
What was the root cause of the incident?
Ask why,
and then
ask why again.
(e.g.
hy?
I
slipped on scrap metal.
hy?
The
ork area
as
not cleaned
up.
Why? I
as
rushing to get project done and did not take time to clean up the work area.)
Suggested Corrective Actions
I hereby certify that the information I have provided is true and accurate. Any inaccurate or false statements may result in
a delay in process of this claim. I further
understand that this information may be used to determine whether the claim will be paid or denied.
Employee Name Signature Date / /
