Actually ,It should be look like Incident report form with all details and required thing also have to cover into task .

A Workplace Incident Report: A workplace incident report is a form that is used to profile physical occurrences that impact an employee's productivity in the workplace. It includes workplace injuries, near misses, and accidents that have a negative impact on the employee (s) and the organization, in general. Usually, labor laws specify the kind of information that should be spelled out in a workplace incident report. This type of incident report may also highlight an employee's concerns with an organization's safety practices, security breaches, and workplace conduct. Examples of workplace incident reports include: A report about sexual harassment or assault in the workplace. A report about a fire incident that occurred within the office premises. Essential details in an effective incident report When designing an incident report form, make sure it covers as many details as possible. Successful incident reports include The type of incident The time and date of the incident Names of the victims - Names of any witnesses A general description of the situation The sequence of events The type of injuries Required medical treatments Video or photo evidence of the injury Task: Design your incident report forms by focusing on essential questions to gather facts about the situation: who, what, when, where, why, and how and write a detail injury report of an employee at your workplace one page in length