202 INJURY / INCIDENT REPORT FORM

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Section 1 - Details of Injury / Incident (To be completed by supervisor)

Name of Injured Person/s

• Enter Name of Injured Person/s

• Enter Name of Injured Person/s

• Enter Name of Injured Person/s

Is the injured person a:

• Employee

  Yes

  No

  N/A

• Contractor

  Yes

  No

  N/A

• Visitor

  Yes

  No

  N/A

If Employee or Contractor, what is the injured person’s role (job title/occupation)?

• Enter (job title/occupation)?

Home Address of injured person

• Enter Home Address of injured person

Home Phone Number:

• Enter Home Phone Number:

Mobile Phone Number

• Enter Mobile Phone Number:

Date and Time of Incident / Injury

• Date and Time of Incident / Injury

  Date

During which shift did the incident occur?

• Morning

• Afternoon

• Evening / Night

What is the location of the accident or where person became unwell? Whether the incident occurred at work place or away from workplace, please provide exact details of the location.

• Enter Location
  Address

What part of the body was injured as a result of the accident?

• Draw what part of the body was injured as a result of the accident?

  Drawing

• Enter what part of the body was injured as a result of the accident?

Describe the nature of the injury/illness. (eg. cut, abrasion, bruising.)

• Describe the nature of the injury/illness. (eg. cut, abrasion, bruising.)rsonnel Name and Company

What was the cause of the injury/illness? (eg. fall from machinery)

• What was the cause of the injury/illness? (eg. fall from machinery)

What treatment was received following the accident? (eg. bandage put on cut, sent to casualty)

• What treatment was received following the accident? (eg. bandage put on cut, sent to casualty)

Were there any Witnesses to the incident? If no, go to section 4

• Yes

• No

Name of Witness 1

• Enter Name of Witness 1

Home Phone Number

• Home Phone Number

Mobile Phone Number

• Mobile Phone Number

Address of Witness

• Address of Witness

Name of Witness 2

• Name of Witness 2

Home Phone Number

• Home Phone Number

Mobile Phone Number

• Mobile Phone Number

Address of Witness

• Address of Witness

Date and time this form was completed:

• Enter Date and time this form was completed:

  Date

Name of Person completing this form

• Enter Name of Person completing this form

Signature of Person completing this form:

• Enter Signature of Person completing this form:

  Sign

Date of notification of injury/illness

• Enter Date of notification of injury/illness

  Date

Today’s Date

• Enter Today’s Date

  Date

Name:

• Enter Name:

Position:

• Enter Position:

Signature of Manager:

• Enter Signature of Manager:

  Sign

Name of Worker / Contractor/ Visitor:

• Enter Name of Worker / Contractor/ Visitor:

Signature of Worker / Contractor/ Visitor:

• Enter Signature of Worker / Contractor/ Visitor:

  Sign