(Your Company Name Here)
(Address) (City, State Zip)
Phone (123) 456-7890 Fax (123) 456-7890
Employee Incident Report
Employee Name: (Name Here) Date: (Date) Supervisor Notes: (Notes Here) Reported by: (Supervisor or Manager) Time: (Time)
Incident Description: (Incident Notes, conclusion and action Here)
Employee Comment: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________
Employee: ______________________________ Date: ______________ Supervisor: _____________________________ Date: ______________