Elderton Group Incident|Injury|Near Miss Report & Investigation

• Injured Persons Name

• Contact Number

• Injured Person's Address

• Employment Details

  Select Self Employee Visitor Contractor

  • Self
  • Employee
  • Visitor
  • Contractor

• Person Completing Form

• Title

• Conducted on

  Date

Details Of Incdent|Injury|Near Miss

• Nature:

  Select Incident Injury Near Miss

  • Incident
  • Injury
  • Near Miss

• Date & Time Of Incident:

  Date

• Address Of Incident:

• Date Reported:

  Date

• Reported To:

• Title:

• Contact Number:

Names Of Witnesses:

Name|Contact Number|Address

• Name:

• Contact Number:

• Address:

Description Of What Happened:

Workplace Conditions At The Time?

Injury Details (If Applicable)

Nature Of Injury|Part of Body|Treatment Recieved

• Nature of Injury:

• Part Of Body Injured:

• Treatment Recieved:

  Select First Aid Doctor Hospital Ambulance

  • First Aid
  • Doctor
  • Hospital
  • Ambulance

Other

• Was any Machinery or Scaffolding Involded?

  Yes

  No

  N/A

• Were photos taken?

  Yes

  No

  N/A

What Action Was Taken Immediately After The Incident?

Can Improvements Be Made As A Result Of This Occurence?

Details|Improvements Completed

• Details:

• Improvements Completed:

Administration

• Will the injury result in lost time?

  Yes

  No

  N/A

• Will workers compensation be claimed?

  Yes

  No

  N/A

• Has WorkCover NSW been informed?

  Yes

  No

  N/A

Signature Of Person Completing Form

• Add signature

  Sign

• Select date

  Date