TEMPLATE

Kansas incident report template

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Your Kansas incident report has 5 rules to meet. ReportDraft puts every one on your checklist and checks your draft before you sign.

  • Disabled past the rest of the shift: report to the Director within 28 days
  • A later death: a supplemental report within 28 days
  • The employee's notice: time, date, place, person and particulars

An incident report template set up for Kansas, with fields for the employee's notice of injury received (date, oral or written, by whom), incapacity beyond the rest of the shift (dates off or restricted) and accident report to the Director (date, by employer or insurer). In Word and PDF.

See a free preview filled from sample notes

REPORTDRAFT.COM
Kansas Incident report Template
Company or organization
Site address or location
Date of the incident
Type of incident
Completed by
Employee's notice of injury received (date, oral or written, by whom)
Incapacity beyond the rest of the shift (dates off or restricted)
Accident report to the Director (date, by employer or insurer)
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Kansas 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 reports to the Director of Workers Compensation, on the Director's form, any accident or claimed accident to an employee that the employer or a supervisor knows of, within 28 days after learning of it, when the injury disables the employee wholly or partly for more than the rest of the day, shift or turn on which it happenedK.S.A. 44-557 (a)
  • If an employee whose accident was reported later dies, a supplemental report goes to the Director within 28 days after learning of the death; these reports are not evidence before the Director, an administrative law judge, the Board or any courtK.S.A. 44-557 (b)
  • Repeated failure to file the required reports brings a civil penalty of up to 250 dollars for each violationK.S.A. 44-557 (c)
  • The employee gives notice of the injury, orally or in writing, by the earlier of 30 calendar days after the accident (weekends included) or 20 calendar days after their last day of employment; the notice gives the time, date, place, person injured and particulars of the injury and makes clear it is a work injuryK.S.A. 44-520 (a), (c) (as amended 2024)
  • If the employer has designated, in writing to employees, a person or department to receive notice of injuries, oral notice to anyone else is insufficient; otherwise notice goes to a supervisor or manager, and written notice goes to a supervisor or manager at the employee's principal work locationK.S.A. 44-520 (a) (2), (3)
  • The notice requirement is waived if the employer or its agent actually knew of the injury, was unavailable to receive notice within the period, or the employee was physically unable to give noticeK.S.A. 44-520 (b)

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 Kansas incident report requirements.