Hazard and Incident Details
Incident Category
- Injury/ Illness
- Property Damage
- Near Hit
- Hazard
- Risk
- Other
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
- Induction
- Task specific
- Trade
- None
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
