Information
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Document No.
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Conducted on
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Personnel
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Audit Title
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INCIDENT NOTIFICATION FORM
ALL INCIDENTS MUST BE REPORTED TO THE SITE MANAGER or SHE COORDINATOR AS SOON AS POSSIBLE. -
WORKPLACE INJURY CATEGORY (tick applicable category)
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Lost Time Injury
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Medical Treatment
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First Aid Treatment
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Near Miss
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Report Details
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Site location
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Name of Person Completing the Report
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Incident Rating (tick applicable rating)
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Actual
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Potential
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INCIDENT LOCATION DETAILS
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Date and Time of Incident
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Location of Incident
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Work Activity being undertaken at time of Incident
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PARTICULARS OF PERSON INVOLVED
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Surname
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First name
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Address
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DOB
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Phone Number
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Employee ID number
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Visitor
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Contractor
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Shift Start Time
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Year Employed in Role
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Occupation
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OTHER PERSONS INVOLVED (tick if applicable)
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Witness
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Client
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Visitor
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Third Party
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Surname
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First Name
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Address
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Contact Telephone
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DETAILS OF INCIDENT
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Account of how incident occurred (including witnesses, brief summary leading up to incident). Includes facts about the sequence of events and the conditions existing at the time i.e. lighting, surface, property damage etc.
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What immediate actions were taken?
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Reported to Manager
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Time reported
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Emergency Services Required? (Tick if applicable)
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Police
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Ambulance
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SES
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Workcover
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PERSONAL INJURY DETAILS
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Part of Body Injured
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Nature of Injury
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First Aid Treatment
- Yes
- No
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First Aid Attendants name
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WorkCover Claim Completed
- Yes
- No
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INITIAL ASSESSMENT OF INJURY
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Injury Type (tick applicable)
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Sprains & Strains
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Fractures
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Foreign Matter
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Crushing Injury
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Burns
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Deafness
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Internal Injury
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Cuts/Abrasions
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Other (describe)
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Part of Body (tick applicable)
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Head/Face
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Arms/Shoulder
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Back/Trunk
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Eye
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Legs/Ankle/Feet
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Hands/Fingers
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Neck
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Hearing
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Other (describe)
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INJURY ASSESSMENT (tick applicable)
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Insignificant
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Minor
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Moderate
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Major
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Catastrophic
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DAMAGE TO PROPERTY OR OTHER EQUIPMENT
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Take photo of damage.
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Describe damage to property - specify Asciano property or other property
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Interim actions taken to prevent reoccurrence.
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Cost of Damage
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SIGN OFF (person completing form) (Print name and sign)
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DATE
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SUPERVISOR/MANAGER (Print name and sign)
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DATE
