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)
Lost Time Injury
First Aid Treatment
Name of Person Completing the Report
Incident Rating (tick applicable rating)
INCIDENT LOCATION DETAILS
Location of Incident
Work Activity being undertaken at time of Incident
PARTICULARS OF PERSON INVOLVED
Employee ID number
Shift Start Time
Year Employed in Role
OTHER PERSONS INVOLVED (tick if applicable)
DETAILS OF INCIDENT
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.
What immediate actions were taken?
Reported to Manager
Emergency Services Required? (Tick if applicable)
PERSONAL INJURY DETAILS
Part of Body Injured
Nature of Injury
First Aid Attendants name
INITIAL ASSESSMENT OF INJURY
Injury Type (tick applicable)
Sprains & Strains
Part of Body (tick applicable)
INJURY ASSESSMENT (tick applicable)
DAMAGE TO PROPERTY OR OTHER EQUIPMENT
Describe damage to property - specify Asciano property or other property
Interim actions taken to prevent reoccurrence.
Cost of Damage