Incident/Injury Report Form


Personal and Incident Details

Full Name

Date of Birth


Contact number

Home address

Email address

Injury Details

Type of injury or disease (e.g burn)

Part/s of the body affected

Date and Time of symptoms

Was medical treatment given?

Treatment provided


Date and Time of treatment

Time lost due to injury?

How many hours/days?

How did the injury happen?


How long had you been working prior to the incident?

How long had you been working on this task?

Is this task part of your normal duties?

Have you been trained for this task?

What were you doing in the time prior to the incident?

Are there any other factors involved (e.g management, work environment, equipment) involved?

What do you think could have been done to prevent this from occuring?

Other comments or observations

What sort of injury occurred?
Type of injury?

Safe Work Method Statements followed?

Equipments/objects/insects involved?

Equipment in good condition?

Date of last service of equipment

Appropriate safety equipment used?

Lighting adequate?

Housekeeping issues contributed?

Surface type
Type of shoes worn

Workload excessive?

Workload boring and repetitive?

Is it a slip or trip?

Height of fall

Were you -
If stairs -
Did you fall on your -

What were you carrying (if anything) at that time?

Does it involve manual handling?

Were your items within easy reach?

Ergonomic equipment available?

Was the equipment being used correctly?

Repititive and forceful movements used?

Action involved

Weight of object

Distance carried/position of object moved from/to

Height of load

For the WHS Manager

Comments and Observation


Person assigned

Target Date
Supervisor or WHS Manager Notification
WHS Manager