Recording an incident as soon as it happens helps you look after the person involved, fix the hazard and meet your legal duties. This internal form does not replace the official OSHA forms, but it collects the facts you will need for them.
Download free (Word .docx)Free · No sign-up · Opens in Microsoft Word and Google Docs · Last reviewed October 2026
Important: please read
This template is a free starting point, not legal advice. MadyHR.ai is not a law firm and cannot give legal advice. Employment law is different in every state, and some cities have their own rules. Laws also change. Before you use this template, check it against the laws where your employees work, and speak to an employment attorney or your state labor department if you are unsure. You use this template at your own risk, and MadyHR.ai accepts no responsibility for how it is used. Links to official government websites are given for information only; MadyHR.ai is not affiliated with or endorsed by any government agency.
When to use this template
Any workplace injury, illness or near miss
Property damage at work
Investigating a safety hazard
Tips before you use it
Get medical help first, paperwork second.
Report to OSHA within 8 hours of a work-related fatality, and within 24 hours of an inpatient hospitalization, amputation or loss of an eye.
Many employers must also record injuries on the OSHA 300 log — check whether your business is covered.
Report work injuries to your workers' compensation insurer as your policy requires.
Rules in your state may differ. Federal law sets the minimum. Your state — and sometimes your city or county — may add extra rules on this topic. Check with your state labor department before you use this template.
Find your state labor office (U.S. Department of Labor)
Template preview
Replace everything in [brackets] and delete the notes for employers before you use it. The Word download contains the full template.
[Company Name]
Workplace Incident Report Form
Incident details
Date of incident
Time
Exact location
Type (injury / illness / near miss / property damage)
Reported to manager on (date and time)
Person involved
Name
Job title
Employee / visitor / contractor
Supervisor
What happened
Describe what the person was doing, what happened, and what equipment or materials were involved.
Description
Injury or illness
Part of body affected
First aid given (by whom)
Medical treatment sought? (Y/N, where)
Did the person leave work early? (Y/N)
Witnesses
Name
Contact details
Statement taken (Y/N)
Follow-up
Immediate cause
Actions taken to prevent it happening again
Reported to OSHA? (required for serious injuries — date and time)
Recorded on OSHA 300 log? (if applicable)
Reported to workers' compensation insurer? (date)
Note for employer (delete before use): Keep medical details confidential and store this form separately from the personnel file.
When do I have to report a workplace injury to OSHA?
Employers must report a work-related fatality within 8 hours, and any work-related inpatient hospitalization, amputation or loss of an eye within 24 hours. OSHA explains how to report on its website.
Is this form the same as the OSHA 300 log?
No. This is an internal report. Employers covered by OSHA's recordkeeping rule must also use the official OSHA forms, which you can get from osha.gov.
Official sources
Each source below is an official U.S. government website. Check them for the latest rules.
We always use a few necessary cookies to sign you in and keep that sign-in safe — those cannot be turned off. We would also like to set marketing cookies (the Meta Pixel and the Reddit Pixel) to measure our advertising. Those are entirely your choice, and everything on this site works exactly the same either way. What each category does.
