Missouri incident report template

Missouri rules for this report

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

• Employers report all injuries to their insurance carrier, or third-party administrator, within five days of the injury or of the day the employee reported it to the employer, whichever is later; the insurer or administrator then files the report with the DivisionRSMo 287.380.1
• Within thirty days after knowing of it, the employer or insurer files with the Division a full report of every injury or death needing medical aid beyond immediate first aid with no further treatment or lost time, giving the employee's name, address, date of birth and wages, the time and cause of the accident, the nature and extent of the injury, medical costs and lost work timeRSMo 287.380.1
• Knowingly failing to report an accident, or knowingly making a false report to the Division, is a misdemeanor punishable by a fine of 50 to 500 dollars, jail of one week to one year, or bothRSMo 287.380.4
• Information in these reports is not disclosed to anyone other than the parties to compensation proceedings and their attorneys, except by order or at a hearing, though the Division may use it for statisticsRSMo 287.380.3
• A claim needs written notice to the employer of the time, place and nature of the injury and the injured person's name and address no later than thirty days after the accident (or after diagnosis of an occupational disease or repetitive trauma), unless the employer was not prejudicedRSMo 287.420

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 Missouri incident report requirements.