Allday Construction Incident Report

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

General Information

• Injured Persons Name:

• Home Address

• Date Of Birth:

  Date

• Occupation:

  Labourer

  Truck Driver

  Operator

  Administration

  mechanic

• Employer:

• Signature of person:

  Sign

Details of Incident:

• Date & Time of Incident

  Date

• Workplace Incident Location

• Activity on which person was partaking at time of incident

• Incident Description:

• Was person trained in to task or work they were permorming?

  Off

  On

• We're SWMS and Job Safety Analysis sheets being used and followed?

  Off

  On

• We're PPE and other safety precautions in place and in use?

  Off

  On

Injury Information:

• Nature of injury, (eg: burn, fracture, sprain)

• Location of Injury:

  Select left foot right foot left leg right leg lower back abdominal left arm right arm left hand right hand neck chest head

  • left foot
  • right foot
  • left leg
  • right leg
  • lower back
  • abdominal
  • left arm
  • right arm
  • left hand
  • right hand
  • neck
  • chest
  • head

Medical Course Of Action:

• Treatment provided by first aid officer?

  Off

  On

• Information by first aid officer:

• Dr or medical centre attended?

  Off

  On

• Date for medical attendance:

  Date

• Treatment provided: (X-ray, prescriptions, Physio)

• Further consultation required?

  Off

  On

• Injury management required?<br>

  Off

  On

• Medical certificate provided?

  Off

  On

• Signature of person providing first aid:

  Sign

Witnesses

• Name of Witness:

• Address and contact number:

• Witness statement:

• Signature of witness:

  Sign

Reporting

• Has supervisor been notified?

  Off

  On

• Supervisors signature

  Sign