TEMPLATE

Louisiana incident report template

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

  • A death or more than a week of lost time: the report to the insurer within 10 days
  • The 30-day notice poster with your name and address
  • The employee's written notice: time, place, nature and cause

An incident report template set up for Louisiana, with fields for the lost time so far (more than one week after the injury triggers the insurer report), employee's written notice received (date) and report sent to the insurer (date). In Word and PDF.

See a free preview filled from sample notes

REPORTDRAFT.COM
Louisiana Incident report Template
Company or organization
Site address or location
Date of the incident
Type of incident
Completed by
Lost time so far (more than one week after the injury triggers the insurer report)
Employee's written notice received (date)
Report sent to the insurer (date)
Download in Word or PDFIncluded with ReportDraft Safety and its free trial.

Louisiana rules for this report

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

  • Within ten days of actual knowledge of an injury that results in death or in lost time of more than one week after the injury, the employer sends a report to its insurer on the form the assistant secretary prescribes, giving its name, address and business, the employee's identifying and contact details and occupation, the cause and nature of the injury, the date, time and particular place, and the employee's wagesLa. R.S. 23:1306 (A)
  • The insurer or claims administrator submits the first report data to the Office of Workers' Compensation Administration in the IAIABC electronic data interchange format, required for submissions after December 31, 2013; the records are confidential, not public, and not subject to subpoenaLa. R.S. 23:1306 (B), (C)
  • The employer keeps posted at a convenient, conspicuous place of business a notice that an injured employee or claimant must give notice to the named employer within thirty days or no payments will be made, and that fraud brings criminal and civil penalties; without the posting, the employee's notice period stretches to twelve monthsLa. R.S. 23:1302
  • No compensation proceeding may be maintained unless notice of the injury reached the employer within thirty days after the injury or deathLa. R.S. 23:1301
  • The employee's notice is in writing, gives the employee's name and address, states in ordinary language the time, place, nature and cause of the injury, and is signed by the person giving itLa. R.S. 23:1303

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 Louisiana incident report requirements.