Incident Report 1.0

• Job No - Job Name - Client

• Conducted on

  Date

• Prepared by

Field Use

• Have you notified your Project Coordinator

  Yes

  No

• Incident Category

  Select Near Miss First Aid Treatment Medical Treatment Injury Lost Time Injury Vehicle/Plant/Equipment Damage Vehicle Accident Service Damage Property Damage

  • Near Miss
  • First Aid Treatment
  • Medical Treatment Injury
  • Lost Time Injury
  • Vehicle/Plant/Equipment Damage
  • Vehicle Accident
  • Service Damage
  • Property Damage

• Specific date and time the incident occurred

  Date
• Specific location of incident
  Address

• Details of the incident

• What things do you believe contributed to the cause of the incident

• What corrective/preventative action has been taken

• What corrective/preventative action do you believe should happen

• Relevant Photos

  Media

• Sketch of incident (where required)

  Drawing

• Witness details of the incident

• Witness full name and signature

  Sign

• Person Responsible full name and signature

  Sign

Office Use

• Project Coordinator to review, assign the appropriate classification and forward an email of confirmation to the WHS Coordinator within the time frames specified in the Incident Procedure

• Project Coordinator

• Classification

• WHS Coordinator comments

• WHS Coordinator

  Sign