Hazard and Incident Details

  • Incident Category

1. Injured Person (if applicable)

  • Take photo of injured person (where appropriate)

  • Name

  • DOB

  • Sex

  • Contact Number/ Email

2. Job Details (if applicable)

  • Job Title

  • How long in this occupation

  • Start time

  • Hours worked

  • Shift arrangement

  • Training/ Qualifications

3. Hazard/ Incident Details

  • Occurred

  • Reported

  • Location of incident
  • Description of hazard incident

  • Description of any of injury, illness or property damage

  • Take/ upload photo evidence of incident, environment, person(s) involved

  • Date reported to regulatory authority (leave blank if not required)

4. Witness Statements (if applicable)

    Witness
  • Name

  • Contact

  • Statement

  • Witness signature (if applicable)

5. Completion

  • Observations and comments

  • Name and signature of reporting person

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