Incident Report Form

• Conducted on

  Date

• Prepared by

• Location
  Address

• Incident Category

  Select Injury/ Illness Property Damage Near Hit Hazard Risk Other

  • Injury/ Illness
  • Property Damage
  • Near Hit
  • Hazard
  • Risk
  • Other

1. Injured Person (if applicable)

• Take photo of injured person (where appropriate)

  Media

• Name

• DOB

  Date

• Sex

  Male

  Female

• Contact Number/ Email

2. Job Details (if applicable)

• Job Title

• How long in this occupation

• Start time

  Date

• Hours worked

  8 hours or less

  More than 8 hours

• Shift arrangement

  Fixed shift

  Rotating shift

• Training/ Qualifications

  Select Induction Task specific Trade None

  • Induction
  • Task specific
  • Trade
  • None

3. Hazard/ Incident Details

• Occurred

  Date

• Reported

  Date
• Location of incident
  Address

• Description of hazard incident

• Description of any of injury, illness or property damage

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

  Media

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

  Date

4. Witness Statements (if applicable)

Witness

• Name

• Contact

• Statement

• Witness signature (if applicable)

  Sign

5. Completion

• Observations and comments

• Name and signature of reporting person

  Sign