TEMPLATE

North Dakota incident report template

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Your North Dakota incident report has 4 rules to meet. ReportDraft puts every one on your checklist and checks your draft before you sign.

  • The employee's notice to a supervisor within 7 days
  • The first report to WSI within 7 days of the employee's notice
  • Every OSHA 301 item, completed within 7 calendar days for a recordable case

An incident report template set up for North Dakota, with fields for the employee's notice received (date, oral or written, by which supervisor) and first report of notice of injury filed with WSI (date). In Word and PDF.

See a free preview filled from sample notes

REPORTDRAFT.COM
North Dakota Incident report Template
Company or organization
Site address or location
Date of the incident
Type of incident
Completed by
Employee's notice received (date, oral or written, by which supervisor)
First report of notice of injury filed with WSI (date)
Download in Word or PDFIncluded with ReportDraft Safety and its free trial.

North Dakota rules for this report

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

  • An employee involved in an accident on the job immediately notifies the employer that it happened and the general nature of the injury, orally or in writing, to the immediate supervisor or another supervisor authorized to receive notice, no later than seven days after the accident (or after the injury became apparent) absent good causeNDCC 65-05-01.2
  • The employer files a first report of notice of injury with Workforce Safety and Insurance within seven days from the date it receives the employee's notice of injuryNDCC 65-05-01.4
  • An employer's failure to file the first report of notice of injury is an admission that the alleged injury may be compensable, and the employer's report may be deemed admitted when WSI decides a claimNDCC 65-05-01.4 ยท N.D. Admin. Code 92-01-02-48 (2) (a)
  • If an employee does not notify the employer of the accident and the general nature of the injury, WSI may consider that failure in deciding whether the injury is compensableNDCC 65-05-01.3
  • A WSI application is complete once WSI has the first report of injury form signed by the injured employee (or someone for them), wage verification if disability benefits are claimed, and provider records showing the type, nature, extent and work-relatedness of the injuryN.D. Admin. Code 92-01-02-48 (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 North Dakota incident report requirements.