Annex A

INCIDENT REPORT FORM

Rehabilitation Leave

I. – EMPLOYEE DETAILS

Name of Employee: ____________________.______________________________ Employee No.: ______________

Position: ___________________________________________________________ Salary Grade: _______________
Sector/Office: ___________________________________________________________________________________
Place of Assignment: ______________________________________________________________________________
Home Address: __________________________________________________________________________________
Contact No.: ____________________ Email Address: _______________

II. – DETAILS OF THE INCIDENT

Date of Incident: ________________________ Time of Incident: ______________ Date Reported: ________________

Work Activity being performed at the time of the Incident: __________________________________________________
Exact Location of Incident:____________________________________________________________________________

Describe in full, the circumstances of the incident (provide attachment if needed)_________________________________

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Names and contact details of witnesses:__________________________________________________________________

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CERTIFICATION

I hereby certify that the foregoing information is true and accurate.

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<Name and Signature of Employee Applying for Rehabilitation Leave/
Family Member/Officemate>

Attested by:

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<Name and Signature of Immediate Supervisor>