ACGC Incident Report

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Employee Details

• Gender

  Male

  Female

• Is the Person a

  Employee

  Member of public or visitor

  Contractor or Agency

  Volunteer or work experience

• Employee Name

• Employee Payroll Number

• Company or Agency Name

• Non-Employee Name

• Non-Employee Telephone Number

Incident Details

• Date & Time of Incident

  Date

• Date & Time Incident Reported

  Date

• Location

• Provide a description of the incident including injury / illness sustained

• Photo of Damage Or Injury

  Media

Type Of Incident

• Incident or Injury

  Incident Only

  No Injury

  Personal Injury

Treatment ( one or more can be selected )

• Nil

  Off

  On

• First Aid

  Off

  On

• Doctor / Specialist

  Off

  On

• Ambulance Called

  Off

  On

• Hospital Admittance

  Off

  On

• Fatality

  Off

  On

• Did the injured person stop work / performance / patronage ?

  Yes

  No

  N/A

• Date & Time Injured Person Stopped Work / performance / patronage

  Date

• Has the injured person returned to work / performance / patronage ?

  Yes

  No

  N/A

• Date / time person returned to work / performance / patronage

  Date

• Is the person reporting the incident the injured worker / performer / patron ?

  Yes

  No

  N/A

• Witness Statement ( include name and contact information )

• Add signature

  Sign

Supervisor Information

• Was the immediate supervisor notified ?

  Yes

  No

  N/A

• Supervisors Name:

• Supervisors Signature

  Sign

• Supervisors Payroll Number

• supervisors telephone number

Office Use ONLY

• Date Received

• Entered By

• RMIS number