INCIDENT/COMPLAINT REPORT - Employee

EMPLOYEE: Return this COMPLETED FORM to your SUPERVISOR as soon as possible.

Name of Person Involved

Address:

City:

Phone Number:

Age:

DOB:

Sex

Female

Male

SSN#

Date of Incident:

Time:

Exact Location of Incident:

EMPLOYEE:

Yes

Were they doing their regular job duties:

Yes

Observed by employee

New Value

Yes

Hire Date

Marital Status

Situation observed only by employee

Yes

Employee Title

Protective Equipment being used:

Yes

If not used, Why:

Description of Incident/Complaint (Who, What, Where, How, Why, Include sequence of events, personnel involved, body part injured, reason incident occurred) (If medication error include brand name, manufacturer, dosage) (Use additional form if necessary)

Actions Taken by Staff Members:

1st Witness Name:

Witness Phone Number:

Witness Address:

2nd Witness Name:

Contact Number:

Witness Address

3rd Witness Name:

Preferred Phone Number:

3rd Witness Address

MEDICAL FOLLOW-UP: Was Medical Attention Sought

Yes

Treatment Refused

Yes

First Treatment Date:

Treating Physician:

Phone Number

Physician Office Address:

First Day Off Work:

Return to Work Date:

Duties Restricted:

Yes

Explain: