Incident Report

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

WHAT HAPPENED?

• Description of Incident (brief factual, no opinions, no conjecture on who was at fault): e.g.: At 10am XX started YY machine and sparks came out exhaust starting a fire which caused WW damage.

WHEN AND WHERE

• Date and Time

  Date

• Specific Location (e.g. maintenance workshop)

• Address of Incident

PEOPLE INVOLVED AND ANY INJURIES

• Names of Personnel involved with Incident

• Injuries Sustained and Action Taken to Assist a) Employees

• b) Other Personnel

• Names and Contact Details of any Witnesses

EQUIPTMENT OR SUBSTANCES INVOLVED

• Note: Tag Out and removed from use until verified safe by competent person. Plant, Equipment, Dangerous Goods or Hazardous Substances Involved:

EXTERNAL/GOVERNMENT REPORTING

• Does this Incident Require Government Reporting?<br>e.g. to WorkSafe authority, EPA or other authority

  Yes

  No

  N/A

• Designated Manager for Government Reporting

  Yes

  No

  N/A

• Government Reporting Complete

  Yes

  No

  N/A

• Date and Time

  Date

• Insurer Notified if Injury or Damage claim Likely

  Yes

  No

  N/A

• Date

INTERIM ACTION

• Interim Action Taken to Prevent Recurrence

• Department Manager to Complete

• Is an investigation required

  Yes

  No

  N/A

• If yes, use investigation form
  If no, enter onto risk register. Tick when entered onto risk register