Incident Report Form by SafetyCulture Care

• Copies forwarded to

  Select General Manager Finance Dept Cleaning Maintenance Human Resources Return to Work Coordinator Other

  • General Manager
  • Finance Dept
  • Cleaning
  • Maintenance
  • Human Resources
  • Return to Work Coordinator
  • Other

• Who does this need to go to?

• Reported Created On

  Date

• Report Created By

• Incident details and investigations MUST be completed prior to end of shift in consultation with your supervisor or manager

• TYPE OF INCIDENT

  Select NEAR MISS INJURY/ILLNESS PROPERTY/EQUIPMENT DAMAGE 󠅧 󠅧 ENVIRONMENTAL OTHER

  • NEAR MISS
  • INJURY/ILLNESS
  • PROPERTY/EQUIPMENT DAMAGE 󠅧 󠅧
  • ENVIRONMENTAL
  • OTHER

• SPECIFY OTHER

• A notifiable incident is when: a person dies, a person experiences a serious injury or illness, a potentially dangerous incident occurs. Significant penalties apply if you do not notify the Safe Work Regulator in your state or territory. You must notify the regulator immediately and insurer with in 48 Hours.

• Is this a notifiable incident?

  Yes

  No

• Contact your manager immediately

DETAILS OF EMPLOYEE INVOLVED

• NAME

• DATE OF BIRTH

  Date

• INJURED PERON'S GENDER

  MALE

  FEMALE

  OTHER

  PREFER NOT TO SAY

• WHAT IS YOUR GENDER?

• ADDRESS
  Address

• HOME PHONE

• MOBILE PHONE

• POSITION/DEPARTMENT

• DATE HIRED

  Date

• STATUS

  FT

  PT

  CS

• SIGNATURE

  Sign

DETAILS OF INCIDENT

• DATE AND TIME OF INCIDENT

  Date

• LOCATION OF INCIDENT

• DATE INCIDENT REPORTED

  Date

• INCIDENT REPORTED TO

• FULL DESCRIPTION OF INCIDENT

DETAILS OF WORK-RELATED INJURY/ILLNESS

• Add drawing

  Drawing

• BODY PART INJURED

  Select EYE HEAD CHEST BACK ABDOMEN ARM HAND/FINGER LEG FOOT/TOE RESPIRATORY OTHER

  • EYE
  • HEAD
  • CHEST
  • BACK
  • ABDOMEN
  • ARM
  • HAND/FINGER
  • LEG
  • FOOT/TOE
  • RESPIRATORY
  • OTHER

• TYPE OF INJURY/ILLNESS

  Select LACERATION ABRASION PUNCTURE BURN FRACTURE STRAIN/SPRAIN AMPUTATION FOREIGN BODY HERNIA CONTUSION OTHER

  • LACERATION
  • ABRASION
  • PUNCTURE
  • BURN
  • FRACTURE
  • STRAIN/SPRAIN
  • AMPUTATION
  • FOREIGN BODY
  • HERNIA
  • CONTUSION
  • OTHER

• SEVERITY OF INJURY/ILLNESS

  Select FIRST AID TREATMENT (ONSITE) MEDICAL TREATMENT (DOCTOR/HOSPITAL) LOST TIME INJURY/ILLNESS

  • FIRST AID TREATMENT (ONSITE)
  • MEDICAL TREATMENT (DOCTOR/HOSPITAL)
  • LOST TIME INJURY/ILLNESS

• NAME OF DOCTOR

• NAME OF HOSPITAL

• DATE ATTENDED

  Date

DETAILS OF PROPERTY/EQUIPMENT DAMAGE

• PROPERTY/EQUIPMENT TYPE AND LOCATION

• DESCRIPTION OF DAMGE

INCIDENT REPORT COMPLETED BY

• NAME, SIGNATURE & SIGN DATE

  Sign

• POSITION

• REC

  Yes

  No

  N/A

RECOMMENDED CORRECTIVE ACTION/S

• undefined