TEMPLATE

Pennsylvania incident report template

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Your Pennsylvania incident report has 6 rules to meet. ReportDraft puts every one on your checklist and checks your draft before you sign.

  • A death: the first report within 48 hours
  • Disabled for the rest of the shift or longer: the first report within 7 days
  • A copy of the first report to the employee when it is filed

An incident report template set up for Pennsylvania, with fields for the date disability began (missed the rest of the day, shift or turn, or longer), "Workers' Compensation Information" given to the employee after the injury (date) and first report of injury filed with the Bureau and copy sent to the employee (date). In Word and PDF.

See a free preview filled from sample notes

REPORTDRAFT.COM
Pennsylvania Incident report Template
Company or organization
Site address or location
Date of the incident
Type of incident
Completed by
Date disability began (missed the rest of the day, shift or turn, or longer)
"Workers' Compensation Information" given to the employee after the injury (date)
First report of injury filed with the Bureau and copy sent to the employee (date)
Download in Word or PDFIncluded with ReportDraft Safety and its free trial.

Pennsylvania rules for this report

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

  • The employer files a first report of injury within 48 hours for every injury resulting in death34 Pa. Code 121.5 (a) (1)
  • For other injuries covered by section 438 of the Workers' Compensation Act, the first report of injury is filed within 7 days after the date disability begins; a disability needing a first report is one continuing the entire day, shift or turn in which the injury was received, or longer34 Pa. Code 121.5 (a) (2), (c)
  • The employer sends a copy of the first report of injury to the employee at the same time it files the report with the Bureau; if there is no disability, a copy is not sent to the Department34 Pa. Code 121.5 (a) (3), (b)
  • Every employee gets the "Workers' Compensation Information" at hire and immediately after an injury, or as soon as possible under the circumstances (after emergency care if the injury needs it)34 Pa. Code 121.3b (a)
  • The information, titled "Workers' Compensation Information" and printed on paper at least 8 1/2 by 11 inches in at least 11-point type, explains wage loss and medical benefits, who pays them and the posting of the insurer's name, that injuries should be reported immediately and late notice can delay or deny benefits, the right to a hearing if a claim is denied, and the Bureau's contact details34 Pa. Code 121.3b (b), (c)
  • The employer posts the name of the company responsible for paying workers' compensation benefits at its primary place of business and its work sites, in a prominent, easily accessible place, including areas used for first aid or treating injured employees34 Pa. Code 121.3b (b) (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 Pennsylvania incident report requirements.