Incident Report

• Contract

• Conducted on

  Date

• Prepared by

• Location
  Address

Incident Details

• Enter job description

• Date and time of incident

  Date

• What was the Incident e.g. Near Miss, Accident?

• Were there any injuries?

  Yes

  No

• Name and address of injured party

• Description of injury

• Take photo of injury (if any visible injuries eg cuts / grazes)

  Media

• Have they required medical attention? (Hospital or doctor - not 1st aid)

  Yes

  No

• Has the accident resulted in any time of work?

  Yes

  No

• How long? (in days)

• Was there any damage to property or plant?

  Yes

  No

• Description of damage

• Take photo of damage

  Media

• What caused the incident?

• Take photo of surrounding environment including any annotations

  Media

• What actions will be taken to eliminate future repeats of the incident?

• Management comments

Sign Off

• Signed off by supervisor when corrective actions have been adopted and monitored

• Supervisor sign off

  Sign