Wisconsin incident report template

Wisconsin 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 under the Act keeps a record of all accidents causing death or disability of an employee in the course of employment, giving the employee's name, address, age and wages, the time and causes of the accident, and the nature and extent of the injuryWis. Stat. 102.37
• An employer reports the death of an employee from a compensable injury to the Department and to its insurance carrier within one day, by telephone, letter, fax or another means the Department authorizesWis. Admin. Code DWD 80.02 (1)
• An insured employer notifies its insurance carrier of a compensable injury within 7 days after the accident when disability continues beyond the 3rd day after the employee leaves work (counting Sunday only if the employee usually works Sundays), or when the carrier is primarily liable for unpaid medical treatmentWis. Admin. Code DWD 80.02 (1) (a), (b)
• The insurer or self-insured employer files the first report of injury (form WKC-12) with the Department by the 14th day after the accident, or within 7 days of hearing of it if the employer told the carrier late, followed by the supplementary report (WKC-13) by the 30th dayWis. Admin. Code DWD 80.02 (2) (a), (b)
• Reports furnished to the Department under the record and payment sections are not admissible as evidence in any action or proceeding arising out of the death or accident reportedWis. Stat. 102.40
• A claim needs actual notice to the employer, an officer, a manager or a designated representative within 30 days after the injury (or after the employee knew or ought to have known it was work-related); if no representative is designated by posters where notices are customarily posted, notice to any superior is enoughWis. Stat. 102.12

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 Wisconsin incident report requirements.