[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-253205-105":53,"doc-detail-253205-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","north-carolina-employee-incident-report-form-instructions","NORTH CAROLINA EMPLOYEE INCIDENT REPORT - Form Instructions","","North Carolina employee incident report form for recording accidents and near hits. Employees complete the report in full with an accurate, truthful account of what occurred, since false or misleading information may trigger disciplinary action and potential legal liability. The submission includes employee details, incident date/time and location, witness information, medical injury notes, a root-cause explanation using a “ask why” approach, and suggested corrective actions. Supervisor review and signatures certify provided information.",{"@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/north-carolina-employee-incident-report-form-instructions/253205/",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/north-carolina-employee-incident-report-form-instructions/253205.png","ImageObject",442,249,{"name":88,"@type":89},"Gloria","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-22","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},"Who is required to complete the incident report form, and what standard must be followed?","Question",{"text":109,"@type":110},"Employees are required to complete the form for all incidents and near hits. The report must be completed in its entirety and provide an accurate, truthful account of the accident or incident.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What happens if an employee provides false or misleading information?",{"text":114,"@type":110},"Providing false or misleading information may lead to disciplinary action, up to and including dismissal, and may also result in additional criminal and/or civil liability. Information may also affect whether a claim is paid or denied.",{"name":116,"@type":107,"acceptedAnswer":117},"How should the root cause of the incident be determined in this form?",{"text":118,"@type":110},"The form instructs the employee to ask why and then ask why again to reach the root cause (with an example given). 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If more room is needed, continue in a Word document and attach it to this submission. |  |  |  |  |\n| --- | --- | --- | --- | --- |\n| 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. |  |  |  |  |\n| Supervisor Review: If an employee is unable to complete this form, the Supervisor must list reason(s) for assisting or completing this report.\u003Cbr>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.\u003Cbr>Supervisor Name: Signature: |  |  |  |  |\n| Employee Information |  |  | Date/Location Information |  |\n| Name (Full): |  |  | Date of Incident: / / | Time of Day: |\n| Employee ID \\#: |  |  | Date Reported to\u003Cbr>Supervisor: / / | Time of Day: |\n| Job Title: |  | 􀀟 Male\u003Cbr>􀀟 Female | Work Address: |  |\n| Telephone \\#: |  |  |  |  |\n| Department: |  |  | Incident Location (address, Building name, office, cross streets, fire name, woods, facility, room \\#, etc.): |  |\n| Agency/University: |  |  |  |  |\n| Supervisor: | Phone \\#: |  |  |  |\n| Date Hired: | Time in Current Job: |  | County: |  |\n| Witness Information |  |  |  |  |\n| Were there any witnesses to the incident? 􀀟 Yes 􀀟 No Number of Witnesses (if applicable):  \u003Cbr>If yes, list all known witnesses/phone \\#’s below, please include additional names on attachment if needed.\u003Cbr>Name: Phone \\#: |  |  |  |  |\n| Name: Phone \\#: |  |  |  |  |\n| Medical Information |  |  |  |  |\n| Part(s) of the body injured: |  |  |  |  |\n| Prior to this accident/incident, have you ever been hurt, suffered injury, or received treatment for the body part(s) listed above? 􀀟 Yes 􀀟 No |  |  |  |  |\n| If yes, please provide the date of prior injury, type of injury, names of treating physician or practice group. |  |  |  |  |\n| Description of Accident/Incident |  |  |  |  |\n|  |  |  |  |  |\n| What was the root cause of the incident? Ask why, and then ask why again. (e.g. Why? I slipped on scrap metal. Why? The work area was not cleaned up. Why? I was rushing to get project done and did not take time to clean up the work area.) |  |  |  |  |\n|  |  |  |  |  |\n| Suggested Corrective Actions |  |  |  |  |\n|  |  |  |  |  |\n| 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. |  |  |  |  |\n| Employee Name Signature Date / / |  |  |  |  |\n\nJanuary 2015","cbCaitEpKAyKVSxi","https://ap.wps.com/l/cbCaitEpKAyKVSxi","pdf",92129,"English","# Instructions\n## Employee completion requirements\n## Supervisor review and certification\n# Employee information\n## Date and location information\n## Witness information\n# Medical information\n## Injured body parts and prior injuries\n# Description and root cause\n## Root cause (ask why twice)\n# Suggested corrective actions\n# Employee certification and signature","[{\"question\":\"Who is required to complete the incident report form, and what standard must be followed?\",\"answer\":\"Employees are required to complete the form for all incidents and near hits. The report must be completed in its entirety and provide an accurate, truthful account of the accident or incident.\"},{\"question\":\"What happens if an employee provides false or misleading information?\",\"answer\":\"Providing false or misleading information may lead to disciplinary action, up to and including dismissal, and may also result in additional criminal and/or civil liability. Information may also affect whether a claim is paid or denied.\"},{\"question\":\"How should the root cause of the incident be determined in this form?\",\"answer\":\"The form instructs the employee to ask why and then ask why again to reach the root cause (with an example given). This root-cause explanation is required in the description section.\"}]","NORTH CAROLINA EMPLOYEE INCIDENT REPORT - Form Instructions | PDF"]