Title Page
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Site conducted
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You are required by law to record injuries and incidents in your company’s own incident and injury register. This document is for site-specific reporting only.
You need to notify WorkSafe if a serious injury, illness or incident happened to a person or people carrying out work, or as a result of work that your business or organisation is responsible for. -
Site Name
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Date
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Simpro Job Number
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Location
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Fantail Employee Name
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Fantail Employee Contact Number
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Fantail Employee Signature
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Site Contact Person:
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Site Contact Number:
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Fantail H & S Representative: Erik Potgieter
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Fantail H & S Contact Number: 021 249 3563
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Document Number
Accident Report
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Site Name:
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Supervisor:
Particulars of Accident/Incident
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Is this an accident or incident
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Date and time of accident/incident
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Location
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Date Reported
The Injured Person
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Name
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Address
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Date of birth
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Phone number
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Length of employment
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What time did the injured person start work
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Type of injury
- Bruising
- Dislocation
- Strain/sprain
- Scratch/abrasion
- Internal
- Fracture
- Amputation
- Foreign body
- Laceration/cut
- Burn/scald
- Chemical reaction
- Other
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Specify injured part of body
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Attach media (if applicable)
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Comments
Damaged Property
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Property or material damaged:
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Attach media (if applicable)
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Nature of damage:
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Attach media (if applicable)
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Object/substance causing damage:
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Attach media (if applicable)
The Accident
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Describe what happened
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Drawing of the accident scene (For vehicle accidents / where appropriate)
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What caused the accident?
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How serious could it have been?
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How often is this likely to happen again?
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What action has or will be taken to stop another accident like this happening?
Action
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Description
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Completed?
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By whom
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When
Treatment and Investigation of Accident
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Type of treatment given
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Name of person giving first aid
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Doctor/Hospital
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Accident/Incident investigated by
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Signature
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Date
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Is the accident/incident a notifiable accident/incident?
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In the event of a notifiable accident/incident, has WorkSafe been advised?
