Sample "Employee Incident Report Letter"

Employee incidents are a common and routine part of any job environment. They can be medical, relational, or safety incidents, but any incident will need to be recorded by Human Resources in an Employee Incident Report Letter. A sample Employee Incident Report Letter can be downloaded below.

To create a Sample Incident Report Letter, include the following information:

  1. Today's Date.
  2. The employee's and supervisor's names and job titles.
  3. Opening Salutation to the Supervisor or HR representative.
  4. Explain the incident that took place as clearly and accurately as possible.
    • If there were any witnesses to the incident, include their names;
    • Explain any injuries (emotional or physical) that occurred as a result of the incident and any treatment you have received since the incident occurred.
  5. If your company will provide care related to the incident, request what type of care you are requesting.
    • If you have a note from a doctor detailing the recommended care, attach a copy of it to the letter.
  6. Mention any time off that you may need to recover from the incident and request information about workers' compensation you may be entitled to.
  7. Close by thanking your supervisor or the HR representative.
  8. Your name and signature.

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Sample Employee Incident Report Letter
From: Tiffany Robbins
9385 Russell Street
Medford, Oregon 70386
+1 569-752-4904
[Date]
To: Evan Lawson
385 Archwood Avenue
Kearny, New Jersey 90637
Dear Mr. Lawson,
In Fairview Boutique on Friday, March 17th, 2020, Jennifer Lynch was stacking shelves
while standing on a ladder in order to reach the top shelf of handbags at 4.10 pm.
As she was stretching to place a bag on the shelf, the ladder collapsed from under her and
she fell to the ground. Her co-worker heard the loud noise and immediately helped her.
Jennifer was in a lot of pain and could not get to her feet as she felt lightheaded. An
ambulance was phoned, and she was brought to the hospital. Jennifer obtained a broken
right arm, bruised thigh and hip, and a bump to the head that left no major head injury.
She was recommended three weeks off work at the minimum by doctors.
The fall was concluded to be nobody else’s fault but was put down to Jennifer
accidentally overreaching instead of moving the ladder to where she needed to see.
Sincerely,
Tiffany Robbins
[Signature]
©
TEMPLATEROLLER.COM
Sample Employee Incident Report Letter
From: Tiffany Robbins
9385 Russell Street
Medford, Oregon 70386
+1 569-752-4904
[Date]
To: Evan Lawson
385 Archwood Avenue
Kearny, New Jersey 90637
Dear Mr. Lawson,
In Fairview Boutique on Friday, March 17th, 2020, Jennifer Lynch was stacking shelves
while standing on a ladder in order to reach the top shelf of handbags at 4.10 pm.
As she was stretching to place a bag on the shelf, the ladder collapsed from under her and
she fell to the ground. Her co-worker heard the loud noise and immediately helped her.
Jennifer was in a lot of pain and could not get to her feet as she felt lightheaded. An
ambulance was phoned, and she was brought to the hospital. Jennifer obtained a broken
right arm, bruised thigh and hip, and a bump to the head that left no major head injury.
She was recommended three weeks off work at the minimum by doctors.
The fall was concluded to be nobody else’s fault but was put down to Jennifer
accidentally overreaching instead of moving the ladder to where she needed to see.
Sincerely,
Tiffany Robbins
[Signature]
©
TEMPLATEROLLER.COM