TEMPLATE

Arizona incident report template

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Your Arizona incident report has 6 rules to meet. ReportDraft puts every one on your checklist and checks your draft before you sign.

  • The carrier and the Commission told within 10 days
  • The insurer's name, address, policy number and expiry, to the employee at once
  • The English and Spanish notice posted, with the rejection forms available

An incident report template set up for Arizona, with fields for the medical treatment given (minor first aid by nonmedical staff is not medical treatment), insurer's name, address, policy number and expiration date given to the employee (date) and report to the carrier and the Industrial Commission (date). In Word and PDF.

See a free preview filled from sample notes

REPORTDRAFT.COM
Arizona Incident report Template
Company or organization
Site address or location
Date of the incident
Type of incident
Completed by
Medical treatment given (minor first aid by nonmedical staff is not medical treatment)
Insurer's name, address, policy number and expiration date given to the employee (date)
Report to the carrier and the Industrial Commission (date)
Download in Word or PDFIncluded with ReportDraft Safety and its free trial.

Arizona rules for this report

These rules are about how and when you report, not the template's fields. Check them before you deliver.

  • Every employer under the Act files with the Industrial Commission and its insurance carrier a full and complete report of every known work injury that results in death or requires medical treatment, in the form and detail the Commission prescribes; medical treatment does not include one-time, short-term treatment by nonmedical staff, such as care for minor scratches, cuts, burns and splintersA.R.S. 23-908 (A)
  • Within ten days after receiving notice of an accident, the employer informs its insurance carrier and the Commission on the Commission's formsA.R.S. 23-908 (G)
  • Immediately on notice of an accident that injures an employee, the employer gives the employee the name and address of its insurance carrier, the policy number and the expiration dateA.R.S. 23-908 (H)
  • The injured employee reports the accident and the injury to the employer forthwith, and the employee's own physician reports to the employer, the carrier and the Commission; the employer may designate in writing a physician for one examination; if the accident is not reported forthwith, or the employee joins in refusing the examination, no compensation is paid unless the Commission excuses the failureA.R.S. 23-908 (E), (F)
  • Anyone failing or refusing to comply with these reporting duties is guilty of a petty offenseA.R.S. 23-908 (J)
  • A compensation claim is valid only if filed with the Commission in writing within one year after the injury becomes manifest or the claimant should know of it, unless the employer or carrier has started paying compensation; when the Commission is notified of an injury, it sends the employee a claim formA.R.S. 23-1061 (A), (B), (C)
  • Every employer keeps posted in a conspicuous place on its premises, in English and Spanish, the statutory notice that employees are deemed to accept the compensation law unless they reject it in writing before any injury, with the rejection forms available where employees are hired; without the notice or the forms, employees hired in that period may sue insteadA.R.S. 23-906 (D), (E)

What is in it

  • What happenedWhat the person was doing just before the incident, with the tools, equipment or material used, then how the incident happened, in the order it happened.
  • Injury or illness and treatmentThe part of the body affected and how, the object or substance that directly caused harm, and the first aid or medical treatment given and where.
  • Damage to property, equipment or the environmentWhat was damaged, spilled or released, and how much, as the notes give it.
  • Immediate actions takenWhat was done right away: first aid, emergency calls, the area made safe, equipment stopped or tagged out, and who was notified.
  • CausesThe immediate cause and any underlying causes the notes identify: equipment, procedures, training, work conditions, supervision. Only what the notes support.
  • Witness statementsName, Role, What they saw or said
  • Corrective actionsAction, Responsible, Due, Status

Rules last reviewed October 15, 2026. Read the full Arizona incident report requirements.