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Collects employee identity and employment details, incident location and timing, a narrative of how the incident occurred and any resulting injury, factual contributing factors and equipment, and injured body parts. Includes sections for involved employees or witnesses, employee agreement with signature, supervisor witness and reporting details, medical information with examining physician and diagnosis, and acknowledgement of referrals, plus a medical records release authorization and workers’ compensation notice.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/employee-incident-report-form/253216/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/employee-incident-report-form/253216.png","ImageObject",442,249,{"name":88,"@type":89},"Rhys","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-29","2026-09-13",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",10,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What information must the employee provide on this report?","Question",{"text":109,"@type":110},"The employee must provide personal and employment details, the incident address, date and time, and a description of how the incident occurred and any resulting injury. The form also requests factual equipment or contributing factors, injured body parts, and other employees involved or witnesses.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What sections are completed by the supervisor?",{"text":114,"@type":110},"The supervisor provides the reporting details (name, incident report date, and department) and answers whether they witnessed the incident, including descriptions or comments. The supervisor also documents what the employee was doing when injured and how the injury occurred, including whether it resulted from mechanical defect or unsafe acts, and whether preventive action was taken.",{"name":116,"@type":107,"acceptedAnswer":117},"What does the medical records release authorization cover?",{"text":118,"@type":110},"It authorizes PMA Insurance Group and related parties to receive applicable medical records and information needed to evaluate the claim and administer benefits. It also includes specific coverage for certain conditions such as AIDS/HIV, mental illness, and drug or alcohol-related problems, and states validity and revocation terms.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},253216,1789264695,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":136,"language":137,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":138,"faqs":139,"seo_title":140,"seo_description":61,"update_tm":126,"read_time":76},687207024643,"https://ap-avatar.wpscdn.com/davatar_3d24733baf745e90a7e4bdd5f77d97b2","EMPLOYEE INCIDENT REPORT  \n| EMPLOYEE INFORMATION – PLEASE TYPE OR PRINT (TO BE COMPLETED BY EMPLOYEE) |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- |\n| NAME (LAST, FIRST, MIDDLE INITIAL) |  |  |  |  |  |  |\n| SOCIAL SECURITY | MARITAL STATUS |  | BIRTH DATE | HOME PHONE |  | \\# OF DEPENDENTS UNDER 18 |\n| REGULAR WORK SCHEDULE TIME |  |  |  | JOB TITLE |  | DATE OF HIRE |\n| CURRENT ADDRESS (STREET, CITY, STATE) |  |  |  |  |  |  |\n| INCIDENT INFORMATION |  |  |  |  |  |  |\n| ADDRESS OF INCIDENT (STREET, CITY, STATE) |  |  |  | DATE OF INCIDENT |  | TIME OF INCIDENT |\n| DESCRIBE HOW THE INCIDENT OCCURRED AND ANY RESULTING INJURY |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |\n| LIST ANY EQUIPMENT, MACHINERY, OR CONTRIBUTING FACTORS TO THE INCIDENT (PLEASE ONLY INCLUDE FACTUAL INFORMATION) |  |  |  |  |  |  |\n| IDENTIFY PARTS OF BODY INJURED: |  |  |  |  |  |  |\n| LIST OTHER EMPLOYEES INVOLVED OR WITNESSES |  |  |  |  |  |  |\n| I AGREE THAT THE ABOVE IS TRUE, CORRECT, AND COMPLETE\u003Cbr>EMPLOYEE’S SIGNATURE   DATE   TELEPHONE \\#  |  |  |  |  |  |  |\n| SUPERVISOR’S REPORT |  |  |  |  |  |  |\n| SUPERVISORS NAME |  |  |  | DATE INCIDENT REPORTED |  | DEPARTMENT |\n| DID YOU WITNESS THE INCIDENT?\u003Cbr>NO YES DESCRIBE/COMMENTS: |  |  |  |  |  |  |\n| WHAT WAS THE EMPLOYEE DOING WHEN INJURED? (BE SPECIFIC, IDENTIFY TOOLS OR MATERIALS INVOLVED AND EXPLAIN HOW THEY WERE BEING USED) |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |\n| HOW DID THE INJURY OCCUR? (DESCRIBE FULLY THE EVENTS RESULTING IN THE INJURY/ILLNESS. NAME ANY OBJECTS OR SUBSTANCES INVOLVED) |  |  |  |  |  |  |\n| DID THE INJURY RESULT FROM MECHANICAL DEFECT?\u003Cbr>NO YES DESCRIBE/COMMENTS: |  |  |  |  |  |  |\n| DID THE INJURY RESULT FROM AN UNSAFE ACT?\u003Cbr>NO YES DESCRIBE/COMMENTS: |  |  |  |  |  |  |\n| WAS ACTION TAKEN TO PREVENT SIMILAR INCIDENTS?\u003Cbr>NO YES DESCRIBE/COMMENTS: |  |  |  |  |  |  |\n| EMPLOYEE WAS REFERRED TO: |  | EMERGENCY ROOM |  |  | REFUSED TREATMENT |  |\n| SUPERVISOR’S SIGNATURE |  |  |  |  | DATE | PHONE |\n| MEDICAL INFORMATION |  |  |  |  |  |  |\n| EXAMINING PHYSICIAN: |  |  |  |  |  | DATE |\n| DIAGNOSIS: |  |  |  |  |  |  |\n\nCOMPLETED FORMS MUST BE SIGNED AND RETURNED TO ENVIRONMENTAL HEALTH AND SAFETY WITHIN 24 HOURS  \nMEDICAL RECORDS RELEASE AUTHORIZATION  \nCLAIM NUMBER:    \nIn order for your claim to be fully evaluated for purposes of determining your eligibility for the receipt of benefits with respect to this claim, you must sign the following authorization. Please note that the amount and type of medical information sought pursuant to this authorization will depend upon the nature of the claim, but that it will be used solely to facilitate determinations regarding the validity of the claim and the payment of benefits or the administration of the insurance program under which the claim has been made. The authorization is subject to your revocation at any time except to the extent that any party has already acted in reliance upon it. Any revocation must be submitted in writing to The PMA Insurance Group, P.O. Box 25250, Lehigh Valley, Pennsylvania, 18002, otherwise this authorization will continue to be valid. Your acceptance of benefits shall be considered an acceptance of the terms in this medical authorization, unless you indicate to the contrary in writing.  \nAuthorization to Release Medical Information  \nI hereby authorize any employer, insurance company, government agency, medical prepayment plan, or service organization, and any physician, surgeon, therapist, pharmacist, or other duly licensed practitioner of the healing arts, and any hospital, including the Veteran’s Administration, or medical transportation company, to release to any of the PMA Insurance Group of Companies (including the PMA Insurance Company and PMA Management Corporation), and their subsidiaries, affiliates, representatives, and agents (collectively PMA), any and all applicable medical records, medical information, and benefit payment information wit","cbCairfTlRt0ljey","https://ap.wps.com/l/cbCairfTlRt0ljey","pdf",413555,8,"English","# Employee Information\n## Incident Information\n# Supervisor’s Report\n# Medical Information\n# Medical Records Release Authorization\n## Authorization to Release Medical Information\n# Workers Compensation - Employee Notification","[{\"question\":\"What information must the employee provide on this report?\",\"answer\":\"The employee must provide personal and employment details, the incident address, date and time, and a description of how the incident occurred and any resulting injury. The form also requests factual equipment or contributing factors, injured body parts, and other employees involved or witnesses.\"},{\"question\":\"What sections are completed by the supervisor?\",\"answer\":\"The supervisor provides the reporting details (name, incident report date, and department) and answers whether they witnessed the incident, including descriptions or comments. The supervisor also documents what the employee was doing when injured and how the injury occurred, including whether it resulted from mechanical defect or unsafe acts, and whether preventive action was taken.\"},{\"question\":\"What does the medical records release authorization cover?\",\"answer\":\"It authorizes PMA Insurance Group and related parties to receive applicable medical records and information needed to evaluate the claim and administer benefits. It also includes specific coverage for certain conditions such as AIDS/HIV, mental illness, and drug or alcohol-related problems, and states validity and revocation terms.\"}]","Employee Incident Report - Form | PDF"]