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Indiana incident report template

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Your Indiana 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, claimed ones included
  • A death or care beyond first aid: the report to the carrier within 7 days
  • The Worker's Compensation Notice with your carrier's details

An incident report template set up for Indiana, with fields for the nature of the employer's business, employee's wages, reportable because of (death, or medical care beyond first aid) and report sent to the insurance carrier, or to the Board if self insured (date). In Word and PDF.

See a free preview filled from sample notes

REPORTDRAFT.COM
Indiana Incident report Template
Company or organization
Site address or location
Date of the incident
Type of incident
Completed by
Nature of the employer's business
Employee's wages
Reportable because of (death, or medical care beyond first aid)
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Indiana 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 keeps a record of all injuries, fatal or otherwise, that its employees receive or claim to have received in the course of employment, and gives the Worker's Compensation Board a copy on requestIC 22-3-4-13 (a)
  • Within seven days after the employer learns of an injury (actual, alleged or reported) that causes death or the need for medical care beyond first aid, the employer sends a written report to its insurance carrier, or to the Board if self insured; the test is meant to match OSHA's 29 CFR 1904.7IC 22-3-4-13 (a)
  • The carrier delivers the report to the Board by the Board's electronic data interchange standards within seven days after receiving it or fourteen days after the employer learned of the injury, whichever is laterIC 22-3-4-13 (a), (b)
  • The report gives the name, nature and location of the employer's business; the injured employee's name, age, sex, wages and occupation; the date and hour of the accident; and the nature and cause of the injuryIC 22-3-4-13 (c)
  • After notice and a hearing, the Board may assess a civil penalty for failing to file the injury record or to post the coverage notice: up to 50 dollars for a first violation, 150 for a second and 300 for a third or later; violating the Act is also a Class C misdemeanorIC 22-3-4-15 · IC 22-3-4-13 (d)
  • The employer posts the Board-approved Worker's Compensation Notice at a conspicuous place of business, where its federal notices are posted, saying employment is covered and giving the carrier's or administrator's name, address and phone number; mobile or remote employees get it electronically or the way other employment information reaches themIC 22-3-2-22 · Worker's Compensation Board of Indiana: Posters
  • Unless the employer already knows, the employee gives written notice as soon as practicable, stating their name and address and the time, place, nature and cause of the injury, signed; without notice or knowledge within thirty days, no compensation is paid until it is givenIC 22-3-3-1 · IC 22-3-3-2

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 Indiana incident report requirements.