Incident report form

• Job

• Conducted on

  Date

• Prepared by

• Location
  Address

Incident Details

• Enter job description

• Date and time of incident

  Date

• What was the Incident/ Near Miss?

• Were there any injuries?

  Yes

  No

• Description of injury

• Take photo of injury

  Media

• Was there any damage to property or plant?

  Yes

  No

• Description of damage

• Take photo of damage

  Media

• What caused the incident?

• Take photo of surrounding environment including any annotations

  Media

• Was the hazard flagged up in the prework risk assessment?

  Select Yes No

  • Yes
  • No

• What actions will be taken to eliminate future repeats of the incident?

• Management comments

Sign Off

• Signed off by supervisor when corrective actions have been adopted and monitored

• Supervisor sign off

  Sign