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

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