Information
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Project
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Date and time incident report completed
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Person completing Incident Report
Incident Classification (one box must be selected. If unsure contact your senior manager or EHS manager)
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Class 1 (Major Incident)
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Class 2 (Moderate - Lost Time, Medical Treatment etc)
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Class 3 (Minor - first aid etc)
Incident Type
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Injury
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Property Damage
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Near Miss
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Environmental
Incident details
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Select date
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Details of incident (state facts only. What we know happened)
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Part of body affected
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Location of where incident occurred, relevant to construction site (e.g northern corner, outside site, second floor, scaffold etc)
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Was worker taken to hospital after the incident?
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Is the workplace regulator required to be notified of this incident?
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Any action taken immediately after incident to prevent further incidents/injuries
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Is an Investigation Report required to be completed?
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Photo of incident scene
Injured worker details (if applicable)
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Name:
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Job title / trade:
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Employer:
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Injured workers address:
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Is there evidence the injured worker was inducted into the construction site?
Short Term Actions Taken
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Actions completed?
Long Term Preventative Actions
Names of any witnesses present
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Incident Report sign off
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Name of person completing report