Title Page

  • Type of Incident

  • Conducted on

  • Name of Manager or Health & Safety Representative conducting investigation:

  • Phone number;

  • Email address:

  • Reported by:

  • Their name/s:

  • The workflow

The Injured Person

  • Name of Injured person:

  • Role:

  • Address of injured person:

  • Occupation of injured person:

  • Age of injured person:

  • Phone of injured person:

  • Email address of injured person:

  • Length of Employment (if a staff member):

  • Was a drug test performed

  • What was the result:

The Incident

  • Date:

  • Place and exact location:

  • Reported to

  • Working conditions at the location and time of the incident (e.g. poor lighting, extreme temperature):

  • Weather conditions at the time of the incident (if applicable):

  • Describe the details in the order of what happened (immediately before, during, and after the incident):

  • Before:

  • During:

  • After:

  • Provide photo taken immediately after incident and/or items directly related to the incident

Nature of Injury: What part of the body is affected and how

  • Was there an injury?

  • Type of injury/illness:

  • Body Part injured:


Identify Immediate Causes

  • Location: (Was there anything at/in the location that caused the incident? If so, why was it there and what needs to be done to address this?):

  • Plant, Equipment and Substances: (Was there anything dangerous about the plant, equipment and/or substances that were used? If so, why was it unsafe and what needs to be done to make it safe?):

  • Procedures: (Was there anything about the procedures, including those for emergencies that caused the incident? If so, what was it and what needs to be done to correct this?):

  • People: (Did anyone do anything that contributed to the incident? If so, why did they do it and what needs to be done to correct this?):

  • Hazard Identification: (Was/were hazard(s) previously identified? If not, why not? What needs to be done to manage this hazard?):

  • Hazard Control: (Were there enough checks done to ensure the safe use of the premises, plant, substances, and procedures? If not, why not? What needs to be done to ensure premises, plant, substances, and procedures create a safe work environment?):

  • Other hazards associated with this incident: (Describe how you currently control hazards associated with this incident? If they failed, why did these controls fail? What needs to be done to control this hazard?):

  • Hazard Management: (Did any of the hazard management systems designed to eliminate or minimise the risk fail? If so, why and what can be done to prevent this from happening again?):

  • Health and Safety Standards used: (Was the correct PPE being used? Describe any best practice or industry standards that are used in your workplace to help manage hazards. Where were they relevant to this incident?):

  • Supervision: (Was there adequate supervision at the time of the incident? If not, why not? What needs to be done to ensure appropriate and effective supervision?):

  • Training: (Was training or instruction in using the equipment, plant, or substance sufficient and effective? If not, why not? What can be done to improve training and/or instructions?):

  • Competence: (Did staff have the right qualification and/or experience to use the tools and procedures for the task they were doing? If not, why not? What can be done to improve competence in using the tools and procedures?):

  • Review: (Is this a repeat of a previous incident? Were corrective actions implemented when there was an incident or when a concern was raised in the past? If not, why not? What needs to be done to implement corrective actions?):

  • Governance: (Was there sufficient oversight by senior managers and/or Officers of the hazards and risks that contributed to this incident? What system for receiving information about key hazards and risks do the senior managers/Officers have in place?):

  • Other causes: (If appropriate, advise what other cause(s) contributed to the incident):


  • Name:

  • Phone:


  • Medical Centre/A&E/Hospital:

  • Doctor:

  • Type of treatment provided:


  • What immediate action has been taken to prevent a reoccurrence?

  • Who?

  • When?

  • Have all preventative actions been reviewed by management and completed?

  • Manager/H&S Representative Sign

Notification and Investigation (WORKSAFE PHONE: 0800 030 040 (24 hours) In the event of a Notifiable Event, an Incident Investigation must be completed and submitted to WorkSafe

  • WorkSafe advised by:

  • Date/Time:

  • Investigation conducted by:

  • Date/Time:

  • Hazard/Risk Register updated by:

  • Date/Time:

  • Notes/Comments:

Incident Investigation Closure

  • This incident investigation can only be closed by an Officer or PCBU after ensuring they have conducted the appropriate due diligence and are satisfied that the corrective actions have been fully implemented.

  • Full name

  • Position

  • Date

  • Signature

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.