Incident / Injury / Near Miss Report & Investigation Form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Injured Persons Details

• Name:

• Contact Number:

• Address:
  Address

• Employment Details:

  Select Self Employee Contractor

  • Self
  • Employee
  • Contractor

Details of Incident/Injury/Near Miss

• Nature:

  Select Incident Injury Near Miss

  • Incident
  • Injury
  • Near Miss

• Date of Incident:

• Date & Time of Incident:

  Date
• Address of Incident:
  Address

• Date Reported:

  Date

• Reported To:

• Title:

• Contact No:

Names of any Witnesses

• Name:

• Contact No:

• Address:
  Address

Describe What Happened

• Enter description

Site Conditions at the Time?

• Enter description

Injury Details (if applicable)

• Nature of injuries (if any):

• Part/s of body injured (if applicable):

• Treatment Recieved?

  Select 1st Aid Doctor Hospital Ambulance

  • 1st Aid
  • Doctor
  • Hospital
  • Ambulance

Other:

• Was any machinery involved?

  Yes

  No

  N/A

• Were any photos taken?

  Yes

  No

  N/A

What action was taken immediately after the incident?

• Enter description

Can any improvements be made as a result of this occurrence?

• Details