Title Page
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Department
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Reported Date and Time
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Incident Date and Time
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Prepared by
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Signed
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Location
Injury - Near Miss - Property Damage
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Injury?
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Injured Person Full Name
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Signed
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Employee Number
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Job Number
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Location/Machine
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First Aider required?
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First Aider Name
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Sent to doctor or hospital?
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Doctor, medical center or hospital name?
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Was an Ambulance Called?
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Which hospital did they take the injured person to?
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Type of Injury (Cut, Sprain/Strain, Bruise, Burns, Penetrating Wounds, Fracture/s, Chemical - etc.)
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Body Part/s affected?
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The left or right or middle part of the body?
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Upper or middle or lower
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How did the injury occur?
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Did this task require a JSA to be completed?
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Was the hazard identified?
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What was the hazard?
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What controls were implemented?
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What controls were in place? (Evidence = Take pictures of documents)
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Pre-op checks are completed?
- Yes
- No
- N/A
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Did this task require a SWMS?
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Was the SWMS signed? Y/N
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Was the hazard identified? Y/N
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What controls were implemented?
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SWMS require updating? Y/N
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(Evidence = Take pictures of documents)
Near Miss
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Was there a Near Miss?
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Brief description of the incident
Property Damage
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Did property damage occur?
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Brief description of the incident
