Incident form

• Who is reporting

  Select

• Date of incident

  Date
• Location
  Address

• Near miss or accident

  Near miss

  Incident

  N/A

• Body parts or equipment affected

• Nature of injury/illness or damage

• Object/equipment/substance inflicting injury/ illness or damage

• Was first aid administered

  Near miss

  Incident

  N/A

• Estimated cost

• Describe activities immediately prior to the incident

• Describe the incident (including individual involved)

• What caused/contributed to the incident

• Rate the probability of recurrence

  Rare

  Occasional

  Frequent

  N/A

• If the incident were to recure, describe how severe it could be

• What actions have or will be taken to prevent recurrence?

Review

• Investigated by?

• Date

  Date

• Follow up review by?

• Date

  Date

• File closed by?

• Date

  Date