Title Page

  • Injured Persons Name

  • Contact Number

  • Injured Person's Address

  • Employment Details

  • Person Completing Form

  • Title

  • Conducted on

Details Of Incdent|Injury|Near Miss

  • Nature:

  • Date & Time Of Incident:

  • Address Of Incident:

  • Date Reported:

  • 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:


  • Was any Machinery or Scaffolding Involded?

  • Were photos taken?

What Action Was Taken Immediately After The Incident?

Can Improvements Be Made As A Result Of This Occurence?

    Details|Improvements Completed
  • Details:

  • Improvements Completed:


  • Will the injury result in lost time?

  • Will workers compensation be claimed?

  • Has WorkCover NSW been informed?

Signature Of Person Completing Form

  • Add signature

  • Select date

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.