Incident Type

Was the incident caused by human error?

Incident type

injured persons details

Was anyone injured?

Turn on if Applicable

Name of injured person:

Date of Birth

Residential Adress:

Contact Number:

E-Mail Adress

Injury reported to:

Date Reported
Initial Treatment Given by:

First Aid Officer (name):

Details of Treatment:

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.