Incident Report

• Document No.

• Simple Interiors Pty Ltd Injury Report

• Prepared by

• Your position

• Contact details

• Conducted on

  Date
• Location
  Address

Incident must be reported immediately. If possible, pictures must be collected to submit to insurance or other parties. Report must be submitted to: Simple Interiors Pty Ltd 19/29 Governor Macquarie Drive Chipping Norton NSW 2170 P:97281184 E: info@simpleinteriors.com.au

Incident

• Type of incident

  Select Bodily Injury Auto Accident Subcontractor injury

  • Bodily Injury
  • Auto Accident
  • Subcontractor injury

• Date of the incident

  Date

• Submitted to Safety

  Date

Details of person involved

• Name of party involved

Details of occurrence:

• Address of occurrence

• Street:

• City:

• State

• Job No. If known

• Describe the occurrence in detail

• Was medical attention given?

  Yes

  No

  N/A

• Describe the treatment given and by whom

• Was the person involved attended to by paramedics or transported to the hospital

  Yes

  No

  N/A

• Please describe

• Please add any supporting photos

  Media

Accident Causes:

• Indicate primary incident cause, and explain reason selected: