Information
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Site conducted
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Name of Business entity and initials of person reporting event
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Name of injured person or registration of asset
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Date & Time
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Location
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First Name and Surname
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Line Manager
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Person/Business Contact Name and Number
Incident Report
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Report type
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Describe the event or hazard and what you did to prevent it escalating.
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Photos
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please select injury type
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Name of injured person
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DOB of the injured person
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Company
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Role/ Trade Type
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Photo ID with current address or Epass
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Address of injured person if no photo ID with no current address available
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Name and contact details of witness
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Activity when injury was sustained
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Where did the injury occur?
- Burbank Site
- BBS Site
- Private Builder
- Office
- External Contractor Site
- Outside of work regime
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Injury Location
- Head
- Face
- Ears
- Eyes
- Neck
- Chest
- Abdomen
- Back
- Shoulder Left
- Shoulder Right
- Arm Left
- Arm Right
- Hand Left
- Hand Right
- Fingers left hand
- Fingers right hand
- Elbow Left
- Elbow Right
- Leg Left
- Leg Right
- Hip left
- Hip Right
- Buttocks
- Groin
- Thigh left
- Thigh Right
- Knee Left
- Knee Right
- Shin Left
- Shin Right
- Ankle Left
- Ankle Right
- Foot Left
- Foot Right
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Type of injury
- Sprian Strain
- Abrasion
- Bruise
- Burn
- Bite/sting
- Concussion
- Crush/Impact
- Electric Shock
- Laceration
- Allergic Reaction
- Amputation/De-Gloving
- Dislocation
- Foreign Body
- Fracture
- Hearing Loss
- Heat Illness
- Hernia
- Internal injury
- Respatory
- Other
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Did a first aid responder provide first aid
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If no please provide reason
- First Aider Unavaliable
- Patient Refused First Aid
- First Aider not able to provide assistance
- No Medical kit avaliable
- other
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Name and contact details of first aid responder
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Did the injured person stop work?
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State date and time
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please provide name, time and contact details of person the incident was reported to
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Name of treating doctor, physician or medical centre
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Has the incident site been protected and undisturbed for so an investigation may proceed and regulator inspect.
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please provide name, time and contact details of person the incident was reported to
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Comments
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Photos
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Type of asset that has been damaged eg: vehicle, plant, scaffold, structure etc.....
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please describe asset type
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How did damage occure
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Details of responsible party
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Has rectification of damage been actioned
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Person/organisation completing rectification work
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did the incident involve any of the following
- Plant
- Vehicle
- Structure
- scaffold
- Electrical asset
- council asset
- Neighbouring property
- overhead structure
- other
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Was the emergency services regulator notified/called to the scene?
- Ambulance
- Fire Brigade
- Police
- SES
- WorkSafe Officer
- Officer of the electrical commissioner
- Power company
- Water utilities
- Gas utilites
- other
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Name/s and contact details of the person attended
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If any person from an emergency service or regulatory office attends the site/scene please contact your line manager and HSE immediately.
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please provide name, time and contact details of person the incident was reported to
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comments
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Photos
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DO NOT ADMIT LIABILITY IN ANY CIRCUMSTANCE - CALL R&C Manager if unsure (exchange driver licence details only)
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please take a photos of the following
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Describe event and actions
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Where the emergency services called, if so provide details
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Has the other driver admitted fault if so please ask the to sign the following statement
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I acknowledge I am at the driver at fault in this instance
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Describe the substance or hazard and what you did to prevent it escalating.
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Photo
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Describe the Plant & Equipment hazard and what you did to prevent it escalating.
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Photo
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Describe the environmental hazard and what you did to prevent it escalating.
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Photo
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Describe the hazard and what you did to prevent it escalating.
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Photo
