Information

  • Project

  • Date and time incident report completed

  • Person completing Incident Report

Incident Classification (one box must be selected. If unsure contact your senior manager or EHS manager)

  • Class 1 (Major Incident)

  • Class 2 (Moderate - Lost Time, Medical Treatment etc)

  • Class 3 (Minor - first aid etc)

Incident Type

  • Injury

  • Property Damage

  • Near Miss

  • Environmental

Incident details

  • Select date

  • Details of incident (state facts only. What we know happened)

  • Part of body affected

  • Location of where incident occurred, relevant to construction site (e.g northern corner, outside site, second floor, scaffold etc)

  • Was worker taken to hospital after the incident?

  • Is the workplace regulator required to be notified of this incident?

  • Any action taken immediately after incident to prevent further incidents/injuries

  • Is an Investigation Report required to be completed?

  • Photo of incident scene

Injured worker details (if applicable)

  • Name:

  • Job title / trade:

  • Employer:

  • Injured workers address:

  • Is there evidence the injured worker was inducted into the construction site?

Short Term Actions Taken

  • Actions completed?

Long Term Preventative Actions

Names of any witnesses present

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

Incident Report sign off

  • Name of person completing report

ONCE COMPLETED FORWARD THIS INCIDENT REPORT TO THE GENERAL MANAGER

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.