Virginia incident report template

Virginia 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 keeps a record of all injuries and deaths of its employees in the course of employment, and within ten days after the injury or death and knowledge of it, a report goes to the Workers' Compensation Commission from the employer, its representative or its insurance carrier, in the Commission's formatVa. Code 65.2-900 (A)
• The accident report gives the employer's name and the nature and location of its business; the injured employee's name, age, sex, wages and occupation; the date and hour of the accident; and the nature and cause of the injury, plus anything else the Commission requiresVa. Code 65.2-900 (B)
• The injured employee, or a representative, gives the employer written notice of the accident immediately or as soon as practicable, stating the employee's name and address, the time and place of the accident, and the nature and cause of the accident and injury; without written notice within 30 days, no compensation or medical benefit is payable unless the Commission accepts a reasonable excuse and the employer was not prejudicedVa. Code 65.2-600
• A first report of injury is filed electronically with the Commission on every injury. An injury may be reported as minor only if it meets none of seven criteria: lost time or partial disability over seven days, medical expenses over 1,000 dollars, a denial of compensability, a disputed issue, a death, a permanent disability or disfigurement, or a specific Commission request; if it later meets one, an updated report follows immediately16VAC30-91-10, 16VAC30-91-20
• An employer, insurer or administrator who fails to make a report the Commission requires is assessed a civil penalty of up to 500 dollars for each failure, and 500 to 5,000 dollars if the failure is willfulVa. Code 65.2-902 (A)
• Every covered employer posts, where employees will see it, the Commission's notice that it complies with the workers' compensation insurance provisions; failing to give that notice to an employee may waive the employer's defense that the employee gave late notice of the accident16VAC30-50-80 (B) (Rule 7)

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 13, 2026. Read the full Virginia incident report requirements.