TEMPLATE

Wyoming incident report template

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Your Wyoming incident report has 7 rules to meet. ReportDraft puts every one on your checklist and checks your draft before you sign.

  • The employee's report within 72 hours, and the injury report within 10 days
  • Your written acknowledgment of the employee's report
  • Your certified injury report to the Division within 10 days, with a copy to the employee

An incident report template set up for Wyoming, with fields for the employee reported the injury to the employer (date and time), employee's written report acknowledged in writing (date), employer's injury report to the Workers' Compensation Division (date), copy of the employer's report mailed or delivered to the employee (date) and employer's statement on the report. In Word and PDF.

See a free preview filled from sample notes

REPORTDRAFT.COM
Wyoming Incident report Template
Company or organization
Site address or location
Date of the incident
Type of incident
Completed by
Employee reported the injury to the employer (date and time)
Employee's written report acknowledged in writing (date)
Employer's injury report to the Workers' Compensation Division (date)
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Wyoming rules for this report

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

  • The injured employee reports the occurrence and general nature of the accident or injury to the employer in writing (or by a means the department approves) as soon as practical and no later than 72 hours after its general nature became apparent, and within ten days files an injury report with the employer and the DivisionW.S. 27-14-502 (a) · Workers' Compensation Division: FAQs (Injured Workers)
  • When the employee, a dependent or a personal representative makes a written report of the injury, the employer acknowledges receipt in writing on the report or a copy of itW.S. 27-14-502 (b)
  • If the employee does not report to the employer and file the injury report on time, the claim is presumed denied unless the employee shows by clear and convincing evidence that the employer and the Division were not prejudiced in investigating the injury and monitoring treatmentW.S. 27-14-502 (c)
  • When an employee reports an injury, the employer files a certified employer's injury report with the Division within ten days after being notified, with the information the director's rules require, and mails or delivers a copy to the employeeW.S. 27-14-506 (a) · Workers' Compensation Division: Report an Injury
  • The employer states on the report either that the injury is compensable and under the jurisdiction of the Act, or that it is not compensable under the Act and whyW.S. 27-14-506 (a) (i), (ii)
  • An employer's willful failure or gross negligence in reporting injuries to its employees is a misdemeanor punishable by a fine of up to 750 dollars, up to six months in jail, or bothW.S. 27-14-506 (c)
  • Each employer keeps the Division's notice, with a brief summary of the Act and the procedures for filing claims, posted in a conspicuous place for employees, and keeps a copy of the Act available to all employeesW.S. 27-14-507

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 Wyoming incident report requirements.