TEMPLATE

Arkansas incident report template

ReportDraft Safety from $12 a month. 14-day free trial with your first report and up to 5 template downloads. Card required, nothing charged today, cancel anytime. Need just one? One incident report for $19, no subscription.

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

  • A record of every injury, however minor
  • The Form P notice posted at each place of business
  • The employee's written notice, and Form AR-N back to them

An incident report template set up for Arkansas, with fields for the employee's written notice of the injury received (date), form AR-N (rights to medical care) given to the employee (date), lost time so far (more than seven days triggers the 10-day report) and report sent to the carrier (date; self-insurers report to the Commission). In Word and PDF.

See a free preview filled from sample notes

REPORTDRAFT.COM
Arkansas Incident report Template
Company or organization
Site address or location
Date of the incident
Type of incident
Completed by
Employee's written notice of the injury received (date)
Form AR-N (rights to medical care) given to the employee (date)
Lost time so far (more than seven days triggers the 10-day report)
Download in Word or PDFIncluded with ReportDraft Safety and its free trial.

Arkansas rules for this report

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

  • The employer keeps a record of all injuries, regardless of their nature, available to the Commission on requestAWCC Rule 099.08 (Ark. Code Ann. 11-9-528)
  • On-the-job deaths, injuries causing more than seven days of lost time, and injuries with compensation due for permanent disability are reported to the Commission within ten days on its forms; self-insurers report directly, other employers only through their carrierAWCC Rule 099.08 (Ark. Code Ann. 11-9-529 (a))
  • All other injuries are reported monthly on the Commission's form as totals: the number of injuries, time lost, medical amounts and the nature of the injuriesAWCC Rule 099.08
  • Claims filed with the Commission include those with more than seven days of disability and controverted medical-only claims; every box on a Commission form is completed, and a form with missing, incomplete or inaccurate information may be rejected and treated as not filedAWCC Rule 099.39 (I) (A)
  • Every employer under the Act keeps the Commission's required notice (Form P) posted on substantial material in a conspicuous place in and about each place of business; an employer using certified managed care also posts the managed care notice (Form H)AWCC Rule 099.07 ยท AWCC Rule 099.33
  • The Commission tells injured employees to report the injury to the employer or supervisor immediately, however slight, and to give written notice of its time, place and nature with enough detail for the employer to arrange treatment and complete its reports; the employer or insurer should give the employee a copy of their rights to medical care (Form AR-N)AWCC: Arkansas Workers' Compensation Questions and Answers

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 Arkansas incident report requirements.