Report

Incident Information

Project Name:

Project Number:

Area of Incident:

Date and Time of Incident:
Date and Time Reported:

Reported to:

Safety Officer:

Contractor:

Section 16(2) / CR 6(1):

Incident Classification:
Loss / Loss Potential:
Affected Person's Details
Particulars:

Names and Surname:

Contact Number:

ID Number:

Age:

Gender:

Occupation:

Injury Classification:
Part of body affected:
Witness' Details
Particulars:

Names and Surname:

Contact Number:

ID Number:

Statement:

Description of Incident:

Photos (at least two):
Investigator's name:
Responsible person's name:
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.