Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

  • This form must be completed for an incident involving injury/illness or reporting a workplace hazard or near miss involving property and/or environmental damage. Incidents involving actual or potential significant injury/illness must be reported immediately to management.

Person Completing the Form

  • First Name

  • Last Name

  • Contact Phone Number

  • Position/Job Title

Incident/Injury/Hazard/Near Miss

  • Description

  • Date and Time of Incident

  • Date and Time Reported

  • Location Details

Incident Type

  • What type of Incident are you Reporting?

  • Was there any 3rd Party Damage, Environmental or Vehicle/Plant Damage?

  • Description of damage caused

Injured/Ill Person Details

  • Family Name

  • Given Name(s)

  • Date of Birth

  • Gender

  • Address

  • Contact Number

  • Occupation

  • Supervisors Name

  • Contact Number

  • Employment Status

Incident Description

  • Explain what Happened

Injury/Illness Details

  • Injury Type

  • Date and Time Duties Modified

  • Treatment Type

  • Description of Treatment Provided

  • Treatment Provided By

  • Contact Number

  • Diagnosis of Injury/Illness

  • Task being undertaken at time of injury/illness

  • What part of the body was injured

Witness Details (if Applicable)

  • Name

  • Address

  • Phone Number

  • Add signature

  • Date

WHAT HAPPENED? (Immediate Cause)

  • Describe what happened

Possible Contributing Factors (select all that apply)

  • Lack of Knowledge

  • Employee Placement

  • Not Enforcing Safe Work Practices

  • Engineering

  • Inadequate Personal Protective Equipment (PPE)

  • Inadequate Maintenance Programs

  • Purchasing Inadequate/Inferior Equipment

  • Inadequate Feedback Systems

  • Unsafe Work Method

Recommended Corrective Action Plan

  • Basic Cause

  • Corrective Action Plan

  • Person Responsible

  • Target Completion Date

Risk Assessment

  • Consequences: Consider what did or Could have happened

  • 1=Death and Extensive Injuries, 2=Medical Treatment, 3=First Aid Treatment, 4=No Treatment

  • Likelihood: How likely could this happen again

  • A=Could Occur in Most Instances, B=Could Occur at Some Time, C=Could Occur, but only Rarely, D=May Occur, but Probably never will

  • Risk Score

Applicants Details

  • Name

  • Position

  • Contact Number

  • Date Recorded

  • Signature

Managers Details

  • Name

  • Position

  • Contact Number

  • Date Recorded

  • Signature

Reporting

  • LTI:

  • MTI:

  • Medical Certificate Required

  • Workcover Notified

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.