Incident and Injury Report Form

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• 1. Select applicable boxes

  Select Incident Injury - Lost Time Injury (LTI) Injury - Medical Treatment Injury (MTI)

  • Incident
  • Injury - Lost Time Injury (LTI)
  • Injury - Medical Treatment Injury (MTI)

• 2. Is this Personal Injury

  Yes

  No
• 3. Site/Location of Incident/Injury
  Address

• 4. Address of Incident/Injury

Particulars of the Incident/Injury

• 5. Date and Time of Incident/Injury

  Date

• 6. Date and Time reported

  Date

• 7. Reported to

• 8. Site Manager / Supervisor informed?

  Yes

  No

• 9. Site Manager / Supervisor's name

10. Details of the Incident/Injury

• Incident/Injury Caused by:

  Select Manual Handling Secondary Sites Heat Stress/Remote Work Environmental Natural Mobile Plant and Vehicles Driving Hazardous Goods Biological Contractors (Maintenance) Working at Height Machinery & Power Tools Emergencies Security Slips, Trips & Falls Electrical Travelling Ergonomics Other

  • Manual Handling
  • Secondary Sites
  • Heat Stress/Remote Work
  • Environmental
  • Natural
  • Mobile Plant and Vehicles
  • Driving
  • Hazardous Goods
  • Biological
  • Contractors (Maintenance)
  • Working at Height
  • Machinery & Power Tools
  • Emergencies
  • Security
  • Slips, Trips & Falls
  • Electrical
  • Travelling
  • Ergonomics
  • Other

• Please provide details if selected "Other"

• Describe the Operation Engaged in at Time of Incident/Injury and how the Incident/Injury Occured

11. Personal Impact

• How Bad Was it?

• How Bad Could it Have Been?

• What is the chance of this happening again?

• Were there any Witnesses?

  Yes

  No

• Please provide the details of witnesses

• Complete the section below for incidents only

• 12. Was there any property, equipment or environmental impacts?

  Yes

  No

• Please provide the details of impact

• 13. What immediate action was taken and/or treatment given?

14. Corrective/Preventive Action to be taken

• Corrective/Preventive Action to be taken

• By Whom

• When

  Date

• Completed?

  Yes

  No

• Please provide the details of what is still to be done

15. Notification to Insurer

• Date of Notification

  Date

• Preferred Contact

• Position

• Signature of person provided the details about the interaction with Insurer

  Sign

• Date of signature

  Date

• Contact number of person provided the details about the interaction with Insurer

• 16. Notification to SafeWork Authority Required?

  Yes

  No

17. Acknowledgements

• Name of the person completing the form

• question below complete for injuries only

• Relationship to injured person

• Signature of person completing the form

  Sign

• Date

  Date

18. Injured Person

• Name

• Signature of injured person

  Sign

• Date

  Date
19. Witness

• Witness Name

• Witness Signature

  Sign

• Date

  Date

20. Health and Safety Representative

• Name of Health and Safety Representative

• Signature of Health and Safety Representative

  Sign

• Date

  Date

Managing Director

• Name of Managing Director of His Representative

• Signature of Managing Director of His Representative

  Sign

• Date

  Date

• Provide a copy of this report to the injured person