INCIDENT REPORT - Novaproducts

• Prepared by

• Conducted on

  Date
• Location
  Address

Details of person involved

• Full name *

• DOB:

• Position/occupation *

• Managers name: *

• Address: *

• Telephone number:

• Email address: *

Incident details

• The Assigned Task / Job Number

• Date of incident: *

  Date

• Location of incident: *

• Time of incident: *

  Date

Name of witnesses to the incident

• Name

• Contact (mobile number or email address)

Injuries To Personal

• Were there any injuries?

  Yes

  No

  N/A

• Description of the injury

• Was there surveillance footage of the event?

  Yes

  No

  N/A

• Is there a photo of the injury?

  Yes

  No

  N/A

Damage To Property or Plant

• Was there damage to property or plant?

  Yes

  No

  N/A

• Description of the damage

• Was there surveillance footage of the event?

  Yes

  No

  N/A

• Is there a photo of the damage?

  Yes

  No

  N/A

Near Miss

• Was there a near miss?

  Yes

  No

  N/A

• Description of the near miss

• Can you get a photo of the near miss?

  Yes

  No

  N/A

• Was there surveillance footage of the near miss?

  Yes

  No

  N/A

What did we do in the following incident?

• Actions

• Change to induction/toolbox

• Change to ongoing training

• Change to work procedure

• Change the work environment

• Equipment maintenances

• Job re-design

• Site clean-up

• Risk assessment review

• Other preventative action

• Can you provide information about the boxes you ticketed in the question above? Please describe it.

Corrective Actions:

• Describe what needs to be done.

• Who is responsible?

• Date for completion

  Date

Consultation

• Who did we consult with when deciding on the actions for the controls?

• Name

• Position

• Contact details (Phone)

Authorised person of corrective action

• Name

• Siganature

  Sign

• Date

  Date