Title Page

  • Site conducted

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  • Report Date

  • Prepared by

  • Location

Employee/Worker Details

  • Name

  • Address
  • Date of Birth

  • Gender

  • Phone Number

Employment Details

  • Job Title

  • Was this a Sub Contractor or HR Focus Employee ?

  • Notify Belinda McLean and Stephen Pauley - 0418 171 270

  • Name of the Contracting Company

  • Notify the Contracting Company of the incident

  • Request the Contracting Company provide you an Incident form

Accident/Near Miss Details

  • Date & Time of Incident

  • How long was the person working prior to the incident ?

  • Accident Type

  • Treatment Given

Injury Details

  • Nature of Injury

  • WHERE did the Accident/Near Miss Happen?

  • HOW did the Accident/Near Miss Happen?

  • Was the person competent for the task ?

  • How serious could the injuries have been?

  • Did the person get ADMITTED to hospital ?

Details

  • What happened?

  • Take at least 5 Photos of the incident area and injury (if possible)

  • What was the ROOT CAUSE of this issue (Why did it occur)?

Completion

  • Has the Safety Officer and/or Belinda McLean been notified ?

  • Worker

  • Site Foreman/Witness/Supervisor

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.