Basic Incident Report

• Prepared by

• Conducted on

  Date

• Brief description of the incident

• Inform incident date and time

  Date

• Incident location

• Location details

Personal Injury

• Was someone injured?

  Yes

  No

• Could someone be injured?

  Yes (Near miss)

  No (Unsafe condition)

  No (Unsafe behaviour)

• Occupancy of the person that could be injuried:

• How could this person be injuried?

  Select Accidental death / natural causes Collision - hit by moving vehicle Collision - hit something fixed or stationary Collision - vehicle to vehicle Contact with a hot surface or substance Contact with electricity Contact with machinery or material being nachined Cut by sharp object (e.g. glass) Drowned or asphyxiated Exposed to a harmful substance Exposed to an explosion Exposed to fire Fall from hight Hit by moving/flying or falling object Injuried by an animal Injuried while lifting/carrying Physical assault by a person Slip/trip or fall on the same level Slip/trip up or down stairs Trapped by something collapsing Violence/intimidation Other

  • Accidental death / natural causes
  • Collision - hit by moving vehicle
  • Collision - hit something fixed or stationary
  • Collision - vehicle to vehicle
  • Contact with a hot surface or substance
  • Contact with electricity
  • Contact with machinery or material being nachined
  • Cut by sharp object (e.g. glass)
  • Drowned or asphyxiated
  • Exposed to a harmful substance
  • Exposed to an explosion
  • Exposed to fire
  • Fall from hight
  • Hit by moving/flying or falling object
  • Injuried by an animal
  • Injuried while lifting/carrying
  • Physical assault by a person
  • Slip/trip or fall on the same level
  • Slip/trip up or down stairs
  • Trapped by something collapsing
  • Violence/intimidation
  • Other

• If other, inform the reason:

• What would have been the most probable outcome of this event?

  First aid

  Medical treatment

  Lost time injury

  Restricted work case

  Fatal

Demages

• Was there a leak / spill / fire or explosion?

  Yes

  No

• Could there have been a leak / spill / fire or explosion?

  Yes

  No

• Was there demage or loss of at least one of the following: vehicle(s), asset(s), tools/equipment, product?

  Yes

  No

• Could there have been demage to at least one of the following: vehicle(s), asset(s), tools/equipment, product?

  Yes

  No