QSEMS-FRM-0222 - Inciden Report Form

  • Site

  • Date

  • Prepared by

  • Location

Incident Report Form

PART A: INCIDENT DETAILS

  • Location of Incident:

  • Incident Classification

  • Reportable To Regulator (Office Use Only)

  • Involved/ Injured Person

  • Position Title

  • Date of Birth (dd/mm/yy):

  • Incident Time / Date

  • Reported By

  • Time / Date Reported

  • Reported To

  • Witness/s

  • Employment Status

  • If Contractor - Company Name

Environmental Incident

  • Environmental Incident Detail (If Relevant)

Damaged Plant / Equipment Detail (If Relevant)

  • ID/Rego #

  • Type

  • Make

  • Model

  • Hours / Kms

  • Year of Manufacture

  • Description of Damage

Nonconformance

  • Nonconformance Detail (If Relevant)

Injury or Illness Detail (if Relevent)

  • Initial Response

  • Is this a Recurrence of a previous injury?

  • Mechanism

  • Agency

  • Nature of Injury

  • Bodily Location

Incident Summary

  • Activity being undertaken at the time of the incident?

  • Describe what happened (including brief description of any injury/damage or environmental harm sustained)

  • What immediate corrective actions were taken (and by whom)

  • Actual Risk Score

  • Potential Risk Score

PART B - TO BE COMPLETED BY THE SUPERVISOR

CAUSAL FACTORS

  • Human Factors

  • Machine Factors

  • System Factors

  • Environmental Factors

  • List any other known contributing factors or physical hazards

  • How did the factors you have ticked off above contribute / cause the incident / why have you selected those factors

Supervisor

  • Print name

  • Signature

  • Date

PART C - REVIEWS & APPROVALS (ALL sections below to be completed for Personal Harm Incidents – Regardless of level of Risk)

PROJECT/OPERATIONS MANAGER – FOR ALL INCIDENTS

  • Are the proposed Corrective/Preventive Actions adequate?

  • Project/Operations Manager Signature

  • Print name

  • Date

MANAGING DIRECTOR – ALL HIGH / CRITICAL RISK INCIDENTS

  • Have the necessary investigations or evaluations been completed?

  • Have corrective actions controlled risk to acceptable level?

  • Date

  • Sign

HSEQ Manager Review - All Incidents

  • Have corrective actions controlled risk to acceptable level?

  • Has an Internal Safety Alert been issued?

  • Print name

  • Signature

  • Date

PART E - Optional

  • ADDITIONAL COMMENTS

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.