Title Page
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Employeez
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Conducted on
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Location
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Site conducted
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Section 1: Personal Details
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Full Name
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Date of Birth
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Department
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Phone Number
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Post Code
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Gender
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Position
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Employment
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Company Name (if contractor)
Section 2: Details of the Incident
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Date and Time of the Incident
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Date Reported
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Reported to
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Activity being performed at the time of incident
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Exact location of incident
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Description of incident (full details including comments made by injured person)
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Has training been provided for this task?
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Name and contact details of witness/s
Section 3: Type of Injury
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Type of
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Body Part that was Injured?
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Laceration/Abrasion
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Bruising
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Fracture/dislocation
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Foreign Body
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Skin Irritation
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Crush Injury
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Dental
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Puncture Wound
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Soft Tissue Injury
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Other (specify)
undefined
Section 4: Part of Body Injured
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Left hand side
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Chest
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Abdomen
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Hip
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Leg
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Right Hand Side
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Groin
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Shoulder
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Elbow
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Finger
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Multiple Injuries
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Hand
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Wrist
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Arm (upper)
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Back (upper)
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Arm (lower)
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Head/face
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Nose
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Back (lower)
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Ears
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Eyes
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Neck
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Toe
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Specify
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Foot
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Ankle
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Knee
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Other (specify)
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Specific details of injury
Section 5: First Aid Treatment
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Tick the appropriate box
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Was any treatment requires
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First Aid
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Went home
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Referred to Doctor
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Ambulance
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Sent to hospital
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Returned to work
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First Aid Attendant
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Treatment given
Section 6
A. Investigation
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Detail the likely cause of accident
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Equipment
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Work Environment
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Specify
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Behavior
B. Asses the Risk
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For each hazard think about how severely could it hurt someone.
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EQUIPMENT: Poor maintenance
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Could happen regularly
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Could happen Ocassionally
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Could happen, but only rarely
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Will probably never happen
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EQUIPMENT: Inadequate training
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Could happen regularly
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Could happen occasionally
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Could happen, but only rarely
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EQUIPMENT: Electrical / mechanical failure
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WORK ENVIRONMENT: Accessibility
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WORK ENVIRONMENT: Design / layout
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WORK ENVIRONMENT: Other
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Specify
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Specify
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Specify
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undefined
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BEHAVIOR: Poor Housekeeping
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BEHAVIOR: Failure to follow procedures
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BEHAVIOR: Speed / Short Cut / Fatigue
Sign Off
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Signature
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Date
Section 7: Incident Report Sign Off
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Report Prepared by
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Position
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Signature
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Date
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Name of person making report (injured or affected person)
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Signature
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Date
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Other Comments
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Please email a copy of the completed form to the Human Resources Department.
