Incident Report Form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Incident Details

• Location of incident
  Address

• Date and time of incident

  Date

• Incident Type

  Select Personnel Injury Environment Property Damage Brand Damage

  • Personnel Injury
  • Environment
  • Property Damage
  • Brand Damage

• Description of Incident

Person Reporting Incident

• Name

• Position

• Sign to confirm information

  Sign

Detail of Injured Person (if applicable)

• Name

• Position

• Sign to confirm information

  Sign

Details of Injury

• Location of Injury

  Select Head Back Elbow Leg Foot Face Trunk Wrist Hip Toes Neck Arm Hand Knee Eye Shoulder Fingers Ankle

  • Head
  • Back
  • Elbow
  • Leg
  • Foot
  • Face
  • Trunk
  • Wrist
  • Hip
  • Toes
  • Neck
  • Arm
  • Hand
  • Knee
  • Eye
  • Shoulder
  • Fingers
  • Ankle

• Other details of injury

• Nature of Injury

  Select Fracture Contusion Burn Dislocation Strain/sprain Crush Laceration / Cut Foreign Body Internal injury Concussion

  • Fracture
  • Contusion
  • Burn
  • Dislocation
  • Strain/sprain
  • Crush
  • Laceration / Cut
  • Foreign Body
  • Internal injury
  • Concussion

• Photo of injury (if appropriate - only take where taking a photo will not delay necessary treatment or otherwise cause harm to the injured person)

  Media

• Treatment required

  Select None Ice Bandage Doctor Hospital Rest (Home) Ambulance

  • None
  • Ice
  • Bandage
  • Doctor
  • Hospital
  • Rest (Home)
  • Ambulance

Containment or mitigation action

• What action is or should occur to prevent a recurrence of the incident?

WHS Reporting

• Was the incident or accident a notifiable occurrence?

  Yes

  No

• Is it a non-disturbance occurrence?

  Yes

  No

  NA

• If yes, has the appropriate authority been notified?

  Yes

  No

  NA

• If yes, have you ensured that the scene will not be interfered with?

  Yes

  No

  NA

Risk assessment

• Has an investigation been undertaken?

  Yes

  No

• Has a risk assessment been conducted?

  Yes

  No

• Have suggested controls been implemented?

  Yes

  No

• Has the risk assessment been included in the risk register?

  Yes

  No

Witnesses

• Witness 1: Enter Name, address and phone

• Witness 2: Enter Name, address and phone

• Witness 3: Enter Name, address and phone