Incident Report

Person filling out form

• Person Reporting Classification

  Employee

  Contractor

  Visitor

• Name?

• Company?

• Site Contact?

• Name?

• Company representing?

• Site Contact?

• Name?

• Role?

• Department?

• Manager?

Person Reporting Incident

• Person Reporting Classification

  Employee

  Contractor

  Visitor

• Name?

• Company?

• Site Contact?

• Name?

• Company representing?

• Site Contact?

• Name?

• Role?

• Department?

• Manager?

• Conducted on

  Date

Incident Details

• Incident Type?

  Select Pain/Discomfort INJURY - No Treatment INJURY - First Aid INJURY - Restricted Work INJURY - Medical Treatment INJURY - Lost Time Property / Plant / Equipment Incident Environmental Incident Vehicle Incident Near Miss / Close Call Unsafe Act Customer Compliant or Quality Incident

  • Pain/Discomfort
  • INJURY - No Treatment
  • INJURY - First Aid
  • INJURY - Restricted Work
  • INJURY - Medical Treatment
  • INJURY - Lost Time
  • Property / Plant / Equipment Incident
  • Environmental Incident
  • Vehicle Incident
  • Near Miss / Close Call
  • Unsafe Act
  • Customer Compliant or Quality Incident

• Location of incident?

  Onsite - Broadmeadows

  Offsite

• Onsite location?

• Offsite location?

• Date and time of incident

  Date

• Time the person involved started shift?

  Date

• What the incident reported immediately?

  Yes

  No

  N/A

• Reason for delay?

• To whom was the incident reported?

• Detailed description of incident. (Include environmental conditions at time of incident)

• Was there any witness(es)?

  Yes

  No

  N/A

• Witness details?

• Immediate actions post incident?

Injury Details?

• Did an injury occur?

  Yes

  No

  N/A

• Injury section?

  Lower

  Upper

  Left

  Right

• Injury location?

  Select Arm / Shoulder Knee / Leg Head / Face / Neck Chest / Abdomen Eye/s Finger / Hand / Wrist Toe / Ankle / Foot Inner Ear / Outer Ear Lungs / Respiratory Back

  • Arm / Shoulder
  • Knee / Leg
  • Head / Face / Neck
  • Chest / Abdomen
  • Eye/s
  • Finger / Hand / Wrist
  • Toe / Ankle / Foot
  • Inner Ear / Outer Ear
  • Lungs / Respiratory
  • Back

• Injury type?

  Select Cut / Laceration / Graze Open Wound Strain / Sprain / Tear Bruise / Swelling Crush Inhalation Fume / Dust Fracture / Dislocation Electric Shock Foreign Body Burns Skin Irritation / Rash Amputation Illness / Diseas Hearing loss Bite Other

  • Cut / Laceration / Graze
  • Open Wound
  • Strain / Sprain / Tear
  • Bruise / Swelling
  • Crush
  • Inhalation Fume / Dust
  • Fracture / Dislocation
  • Electric Shock
  • Foreign Body
  • Burns
  • Skin Irritation / Rash
  • Amputation
  • Illness / Diseas
  • Hearing loss
  • Bite
  • Other

• Treatment provided?

  Yes

  No

  N/A

• Treatment provider?

Property / Plant / Equipment Damage?

• Was property / plant / equipment damaged?

  Yes

  No

  N/A

• Name?

• Make / Model?

• Picture

  Media

• Does operation require license?

  Yes

  No

  N/A

• Photo of license?

  Media

Signatures

• Person filling out form

  Sign

• Person reporting incident

  Sign

• Manager

  Sign