Incident or Hazard Report Form

What report type you want to make ? (choose one)

• Incident

• Injury

• Fleet / Asset

• Hazard

Nature of report ? (choose one)

• Near miss

• Personal injury

• Death

• Asset damage

• Assault

• Physical threat

• Verbal abuse

• Other

• Please describe the nature of report here

• Date of incident / hazard

  Date

• Name of person completing this form

• Position

• Phone number

• email address

• Location of the incident / hazard

• Description of incident / hazard, how did it occur

• Where there any contributing factors?

• Is there any other witness for this incident / hazard report

  Yes

  No

  N/A

• Name of witness

• Witness contact details

• Any injured person ?

  Yes

  No

  N/A

• Name of the injured person

• Describe the injury (which part of body, how bad is the injury etc.)

• 

• Injury treatment

• No treatment

• First aid treatment

• Doctor / Medical centre

• Hospital - outpatient

• Hospital - Inpatient (kept overnight)

• Other

• Please describe the other treatment given here

• Treatment details

• Name of treatment provider

• Treatment provider contact details

• Do you have any recommendation for corrective action

  Yes

  No

  N/A

• List your suggestions here. What do you suggest happens so the incident / hazard does not occur again?

• Signature of the person completing this form

  Sign

• Please send the completed incident report to your direct supervisor and whs@nlc.org.au within 24 hours of the incident occurring or hazard being identified.