Incident Report Form

Use this form ONLY if there is an injury or a Workcover reportable accident. THIS PAGE IS TO COMPLETED BY THE EMPLOYEE (with team leader’s assistance If required) AND HANDED TO THE TEAM LEADER AS SOON AS PRACTICABLE AFTER THE INCIDENT (any of the above) THIS FORM MAY BE COMPLETED BY A THIRD PARTY ON BEHALF OF AN INJURED EMPLOYEES WHO IS UNABLE TO DO SO.

Information

Document No.
Location
Date of Report
Employee Injured / Involved in incident
Time Work Commenced
Time Work due to Finish
Occupation / Classification
Home Address
Report Prepared by

Incident Report

AFFECTED EMPLOYEE WILL BE PROVIDED WITH A COPY OF THIS REPORT AS ACKNOWLEDGMENT OF NOTIFICATION OF THE INCIDENT
Date and Time of Incident
Date and time work ceased by employee
Date and time incident was reported to Team Leader
Team Leader
Task at Time of Incident
Experience in this task (Years & Months)
Describe the location of the incident
Type of Accident (Manual Handling, Fall, Impact, etc.)
People or Objects Involved (Machinery, other person, tools etc.)
Type of Injury (Bruising, strain, fracture etc.)
Body Part(s) Effected (Head, foot, hands, lower back, etc)
Employee Signature
Witness To Incident

Teamleader Investigation

Where possible this investigation is to be jointly undertaken by the employee, Teamleader and OH&S Representative. The Teamleader must inform the OH&S Representative where practicable of the Incident and the investigation actions.
Identify all the hazards applicable as the causing factors of this Accident, Injury, Near Miss. (Select all applicable)
- Yes
- No
- N/A
Image, if 'Other' is selected
RISK MANAGEMENT
In your opinion what action should be taken to remove or minimise the hazards (include the action already taken)
What actions are recommended to prevent a recurrence of this incident? ( Please indicate time frame, estimated cost, completion date and persons responsible)
Photographs where applicable
Drawing that may be applicable to incident
Investigation performed by
OH&S Representative if applicable
Agree with information supplied by the involved

OPERATIONS MANAGER

What is the overall likely level of the severity of the incident?
What is the chance of such injuries recurring?
I have sighted this form and checked that all relevant details are provided and consistent.
I have classified this as an
Add signature
Additional notes