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