General Staff Incident Report

• Site

• Report Date

  Date

• Prepared by

• Location
  Address

Employee Details

• Name

• Address
  Address

• Date of Birth

  Date

• Gender

  Male

  Female

• Phone Number

Employment Details

• Job Title

• Employment Status

  Permanent

  Casual

  Contractor

  Visitor

Accident/Near Miss Details

• Date & Time

  Date

• Hours at Work

• Accident Type

  Near Miss

  Incident - No Lost Time

  Accident - No Lost Time

  Accident . - Lost Time

• Treatment Given

  No Treatment

  First Aid

  Doctor

  Hospital

  Serious Harm

Injury Details

• Nature of Injury

  Select No Injury Sprain/Strain Bruising Cut Burns Head Injury Poison/Chemical Fracture/Break Multiple Injuries Gradual Process

  • No Injury
  • Sprain/Strain
  • Bruising
  • Cut
  • Burns
  • Head Injury
  • Poison/Chemical
  • Fracture/Break
  • Multiple Injuries
  • Gradual Process

• Mark Injuries

  Drawing

• Where did the Accident/Near Miss Happen?

• How did the Accident/Near Miss Happen?

• Was the person trained for the task they were doing?

  Yes

  No

• Was a vehicle involved?

  Yes

  No

• Type of Vehicle

• Was a significant hazard involved?

  Yes

  No

• What was the significant hazard?

• Is the hazard on the hazard register?

  Yes

  No

• How serious could the injuries have been?

Details

• What happened?

• Doctor visit is required?

  Yes

  No

• Initial Needs assessment

  Select Able to continue Full Duties Able to do Light Duties Unable to Work Help Available at Home Assistance required at home Transport Assistance Needed

  • Able to continue Full Duties
  • Able to do Light Duties
  • Unable to Work
  • Help Available at Home
  • Assistance required at home
  • Transport Assistance Needed

Action Plan

• Add steps to prevent a similar event from happening. Add action details in the paperclip icon.

Action Plan

• Action Plan Summary

Completion

• Worker

  Sign

• Health & Safety Manager

  Sign

• Management

  Sign

• Treating Doctor

  Sign