Information
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Document No.
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Client / Site
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Conducted on
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Prepared by
Incident Report
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Name of person involved in incident
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Date and time of incident
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What was the type of incident?
- Near Miss
- Close Call
- First Aid
- Aches or Pain
- Doctor
- Hospital
- Damage
- Chemical Spill
- Gas Leak
- Natural Disaster
- Other
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What happened (how did it happen)
- Fall, trip, slip
- Lifting or moving
- Hitting objects with body
- Being hit by an object
- Mental stress
- Body stress, exhaustion
- Biological factors
- Heat, radiation or energy
- Sound or pressure
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Where on the body was the injury
- Face/Head
- Eye
- Mouth/Teeth
- Nose
- Ear
- Neck
- Hand/Fingers
- Arm
- Shoulder
- Chest
- Back
- Stomach area
- Groin
- Upper Leg
- Knee
- Lower Leg
- Ankle
- Foot
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Take a picture of the injury
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Left or Right
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What was the nature of the injury?
- Laceration
- Abrasion
- Sprain
- Fracture
- Dislocation
- Bruise
- Skin Disorder
- Burn/Scald
- Dental
- Internal
- Amputation
- Fatal
- Inhalation
- Poisoning
- Hearing Loss
- Hernia
- Suffocation
- Other
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What caused the incident (agency)
- Power tools or equipment
- Hand tools or equipment
- Material or substance
- Vehicle
- Environment - dust etc
- Chemical
- Animal, human, biological
- Bacteria/Virus
- Other
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Describe your injury or possible incident
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Take a picture of the possible incident/near miss situation
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How did this happen or what could have happened
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Is this serious harm?
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Is an investigation required?
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Person Reporting Incident
