Incident Report Form - UCR WA

• Title (Incident - Your Name - Date of Incident)

• Site

  Select

• Date reported

  Date

• Who is reporting?

  Select Myself I am lodging this form on behalf of someone else

  • Myself
  • I am lodging this form on behalf of someone else

• Reported by

• Email of person reporting

First Incident Details

• Date & Time of Incident

  Date
• Location of Incident
  Address

• Incident Priority?

  Urgent

  High

  Medium

  Low

  Trivial

• Incident Type?

  Select Hazard Near-Miss Slip & Fall Accident Injury Theft Fire Property Damage Fatality Illness Other Reportable / Notifiable Loss Time

  • Hazard
  • Near-Miss
  • Slip & Fall
  • Accident
  • Injury
  • Theft
  • Fire
  • Property Damage
  • Fatality
  • Illness
  • Other
  • Reportable / Notifiable
  • Loss Time

• Please describe type of incident

• Name of on-duty supervisor at time of incident?

• Is immediate medical attention required?

  Yes

  No

• What kind of medical attention was administered?

  Select First Aid Doctor Consulted Hospital Ambulance Medical Attention Declined

  • First Aid
  • Doctor Consulted
  • Hospital
  • Ambulance
  • Medical Attention Declined

Describe What Happened

• Describe what happened. Please be detailed but state only facts.

• What were the weather / environmental conditions at the time of the incident?

  Select Clear Cloudy Rain Snow Windy Heatwave Haze Other

  • Clear
  • Cloudy
  • Rain
  • Snow
  • Windy
  • Heatwave
  • Haze
  • Other

• Describe the weather / environmental conditions at the time of the incident

Record Evidence and Information

• Which of the following do you need to attach to this report to accuractly document this incident?

  Select Evidence Equipment Details Vehicle Details Damages Other Items

  • Evidence
  • Equipment Details
  • Vehicle Details
  • Damages
  • Other Items

Evidence Log

• Please log all relevant evidence below

Evidence

• Evidence Description

• Evidence ID number (if applicable)

• Type of evidence

  Document

  Photos

  Other

• Photos of evidence (if applicable)

  Media

• Please detail any further information regarding this evidence (if applicable)

Vehicle Log

• Please log all relevant vehicle details below

Vehicle

• Vehicle Make

• Vehicle Model

• Vehicle Registration

• Driver (if applicable)

• Photos of equipment (if applicable)

  Media

• Please detail any further information regarding this vehicle (if applicable)

Damage Log

• Please log all relevant damage details below

Damage

• Damage description

• ID number (if applicable)

• Photos of damage (if applicable)

  Media

• Please detail any further information regarding this damage (if applicable)

Other Items Log

• Please log all relevant details of other items below

Item

• Item description

• ID number (if applicable)

• Photos of item (if applicable)

  Media

• Please detail any further information regarding this item (if applicable)

Equipment Log

• Please log all relevant equipment details below

Equipment

• Equipment Make

• Equipment Model

• Equipment ID number (if applicable)

• Photos of equipment (if applicable)

  Media

• Please detail any further information regarding this equipment (if applicable)

People involved

• Please document all people involved in this incident, including yourself (the person reporting the incident)

Person

Person

• Full Name

• ID number

• Contact phone number

• What is this person's relation to the incident? (select all that apply)

  Select Reporter of incident Injured person Witness Primary person involved Secondary Involvement On-duty supervisor Investigator Suspect Other

  • Reporter of incident
  • Injured person
  • Witness
  • Primary person involved
  • Secondary Involvement
  • On-duty supervisor
  • Investigator
  • Suspect
  • Other

• Describe this person's relation to the incident

• Please describe this person's involvement with the incident, including all relevant information

• Does this person wish to make a preliminary statement?

  Yes

  No

  N/A

Preliminary Statement

• Statement regarding incident

• Person Signature

  Sign

• Has this person sustained an injury?

  Yes

  No

Injury Details

• Type of injury or illness? (select all that apply)

  Select Superficial Open Wound Fatality Concussion Sprain Respiratory Eye Injury Burns Fracture Electrocution Fall Strain Dislocation Struck by object Entanglement Assault Muscle & Tendon Nerve & spinal cord Amputation Intracranial Other Injury

  • Superficial
  • Open Wound
  • Fatality
  • Concussion
  • Sprain
  • Respiratory
  • Eye Injury
  • Burns
  • Fracture
  • Electrocution
  • Fall
  • Strain
  • Dislocation
  • Struck by object
  • Entanglement
  • Assault
  • Muscle & Tendon
  • Nerve & spinal cord
  • Amputation
  • Intracranial
  • Other Injury

• Describe type of injury or illness

• Parts of body affected? (select all that apply)

  Select General Ailment Head Eye (Left) Eye (Right) Ear Nose Throat Neck Back (Upper) Back (Lower) Arm - Upper (Right) Arm - Upper (Left) Arm - Elbow (Right) Arm - Elbow (Left) Arm - Forearm (Right) Arm - Forearm (Left) Wrist (Right) Wrist (Left) Hand (Right) Hand (Left) Chest Abdominal / Stomach Groin / Anus Leg - Upper (Right) Leg - Upper (Left) Leg - Knee (Right) Leg - Knee (Left) Leg - Lower (Right) Leg - Lower (Left) Ankle (Right) Ankle (Left) Foot (Right) Foot (Left) Shoulder (Left) Shoulder (Right) Other

  • General Ailment
  • Head
  • Eye (Left)
  • Eye (Right)
  • Ear
  • Nose
  • Throat
  • Neck
  • Back (Upper)
  • Back (Lower)
  • Arm - Upper (Right)
  • Arm - Upper (Left)
  • Arm - Elbow (Right)
  • Arm - Elbow (Left)
  • Arm - Forearm (Right)
  • Arm - Forearm (Left)
  • Wrist (Right)
  • Wrist (Left)
  • Hand (Right)
  • Hand (Left)
  • Chest
  • Abdominal / Stomach
  • Groin / Anus
  • Leg - Upper (Right)
  • Leg - Upper (Left)
  • Leg - Knee (Right)
  • Leg - Knee (Left)
  • Leg - Lower (Right)
  • Leg - Lower (Left)
  • Ankle (Right)
  • Ankle (Left)
  • Foot (Right)
  • Foot (Left)
  • Shoulder (Left)
  • Shoulder (Right)
  • Other

• Please describe injury location

• Describe this injury or illness

• What was the cause of this injury or illness?

Corrective Actions

• Are corrective/further actions required with regard to this incident?

  Yes

  No

• Have all required corrective actions been added as Actions to this inspection?

  Yes

  No

  N/A

• Please add any corrective actions to the appropriate questions above before completing this incident report

Sign Off

• Further action/follow-up/investigation required?

  Yes

  No

• Name of person/people to follow up

• Name & Signature of Reporter

  Sign