Hazard, Injury & Incident Reporting - First Response

• Document No.

• Name of person reporting

First Incident Details

• Date & Time of Incident

  Date
• Location of Incident
  Address

• Incident Priority?

  Urgent

  High

  Medium

  Low

  Trivial

• Incident Type?

  Select Hazard Near-Miss Injury Accident Slip & Fall Illness Theft Property Damage Fire Fatality Other

  • Hazard
  • Near-Miss
  • Injury
  • Accident
  • Slip & Fall
  • Illness
  • Theft
  • Property Damage
  • Fire
  • Fatality
  • Other

• How serious could it have been?

  Catastrophic or Fatal

  Major

  Minor or moderate

  None

• Likelihood of occurrence

  Highly unlikely (Rare)

  Unlikely

  Moderate

  Likely

  Highly Likely

• If an incident did occur, how serious could it be?

  Catastrophic or Fatal

  Major

  Minor or moderate

  None

• Name of on-duty supervisor at time of incident?

• Immediate medical attention required?

  Yes

  No

• What kind of medical attention was administered or required?

Describe What Happened

• Describe what happened. Please be detailed but state only facts.

Record Evidence and Information

People involved

• Document other people involved in the incident.

Person

• Do they wish to make a statement?

  Yes

  No

  N/A

• undefined

Corrective Actions

• Are corrective/further actions required with regard to this incident?

  Yes

  No

• Have all required corrective actions been added as Actions to this inspection?

  Yes

  No

  N/A

• Please add any corrective actions to the appropriate questions above before completing this incident report

Sign Off

• Further action/follow-up/investigation required?

  Yes

  No

• Name of person/people to follow up

• Name of person reporting