5. Incident/injury report

• Document No.

• Job# / site#

• Conducted on

  Date

• Prepared by

• Location
  Address

Class of incident

• Type of incident

  Select injury near miss property/plant damage environmental other

  • injury
  • near miss
  • property/plant damage
  • environmental
  • other

• Reported

  Yes

  No

  N/A

• Further action required

  Yes

  No

  N/A

Injured persons details

• Name

• Address

• Date of birth

• Phone #

• Occupation

• Next of kin name

• Phone#

• N.B. Please refer to site induction if information can not be obtained at time of incident

Details or incident

• Date & time

  Date

• Nature of incident

• Location of incident

• Description of incident

• Details of damage to property/plant/ equipment

• Photos of incident

  Media

• Witness

• Witness phone

Recommended prevention action

• Details

Completed by

• Name

  Sign

• Position

• Time & date

  Date