Incident Report

A. What Kind of Incident Occured?

  • INJURY

  • Name of person injured:

  • The injured person was a

  • Employee number:

  • What treatment was provided?

  • Did the injured person return to work on the same day?

  • When did the injured person return to work?

  • Select date

  • The incident must be reported to WorkCover. You can phone in or report the incident online.

  • Possible lost time injury

  • When did the injured person return to work?

  • Are alternative duties required or has a RTW plan been provided for the injured worker? Please attached relevant documentation (medical certificates, RTW plan).

  • What duties can the injured person perform?

  • What caused the injury (statement by injured person)?

  • Type of injury (cut, strain, heat stroke, crush injury etc):

  • Part of body (finger, right hand, ankle, calf etc):

  • Take photos of injury, cause of injury and work area.

  • PROPERTY DAMAGE

  • Describe what was damaged:

  • Take photos of product, equipment and area around incident.

  • Report damage to customer (full name of person reported to)

  • NEAR MISS

  • Describe what happened:

  • When did the near miss occur?

  • Take photos of the work area or where the near miss occurred.

B. Notification

  • Has the customer been notified of the incident?

  • Who was the person representing the customer the incident was reported to (full name) ?

  • NOTIFY THE CUSTOMER IMMEDIATELY: Provide the full name of person reported to.

C. INVESTIGATOR'S REPORT:

  • Why did the incident occur? Give a full explanation of causes identified:

D. IMMEDIATE ACTIONS TAKEN:

  • Detail steps take to prevent short term re-occurance:

E RECOMMENDATIONS FOR FURTHER ACTIONS:

  • List additional steps or processes necessary for permanent correction:

F. SIGNATURES

  • Person Involved in the incident:

  • Add signature

  • Person reporting the incident: (if same as above, leave blank)

  • Add signature

  • Person completing the incident report

  • Add signature

  • Manager

  • Add signature

G. NOTES & IMAGES

  • Please provide any additional notes:

  • Please provide any additional images that may help with the investigation of the incident:

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