Report Occupational Incident

Injured Person Information Step 1 of 4

First Name

Surname

Designation

Department

ID Number

EC Number

Home Address

Phone Number

Email Address

Incident Details Step 2 of 4

Date of Incident

Time of Incident

Incident Type

Description of How the Incident Occurred Min. 20 characters

Be as specific as possible — include actions leading up to the incident, equipment involved, and any contributing factors.

0 / 2000

Location & Facility Information Step 3 of 4

Facility Type

Province

District

Health Facility

Immediate Supervisor Information Step 4 of 5

Supervisor Designation

Supervisor Name

Witness Information Step 5 of 5

Please provide details for witnesses who observed this incident. Witnesses will receive an SMS with a secure link to submit their statements.

Full Name

Phone Number

Format: +263 or 07xx

Full Name

Phone Number

Format: +263 or 07xx

0 / 2 witnesses added

Consent & Authorization Acknowledgement

By submitting this incident report, I confirm that:

I agree and authorize the submission of this incident report Required