Incident Report

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• I am reporting

  Damage

  Near Miss

  Illness

  Injury

• If injury, what sub-category

  First Aid Injury

  Medical Treatment Injury

  Restricted Work Injury

  Lost Time Injury

  N/A

Contact Details

• Name of person involved

• Contact number

• D.O.B

• Gender

  Male

  Female

• Emergency contact name

• Emergency contact number

Incident Details

• Date of incident

  Date

• Address of incident

• Task being performed

• First person informed of incident

• Witness name

• Witness contact number

• Witness comments

• Describe the incident (events leading up to and including the incident, including all details such as work conditions and extent of damage)

• Why did the incident occur? (List all relevant factors which may have caused incident)

• Was proper first aid administered following the incident?

• Treatment given

• Has the insurer been notified

  Yes

  No

  N/A

• What corrective action will be taken

Sign Off

• Name of person completing report

• Signature

  Sign

• Time and Date

  Date

• Signature of person involved

  Sign

• Time and date

  Date

• Reviewed by senior management

  Yes

  No

  N/A

• Please upload any relevant photos or documents related to the incident.

  Media