Title Page

  • Type of Incident

  • Conducted on

  • Name of person filling in form

  • Reported by:

  • Their name/s:

  • Their email address/es:

  • Their phone number:

  • The workflow

Particulars of Incident

  • Date:

  • Location:

  • Name of Injured person:

  • 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:

  • Particulars of Incident (Describe what happened, add photos or take a picture of a drawn diagram)

  • Nature of Injury (What part of the body is affected and how, take pictures if applicable and permission given):

  • Property Damage (What damage was caused and how):

  • Analysis (What do you think caused or contributed to the incident)?

  • Prevention (What action has been taken to prevent a reoccurrence)?

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

  • Name of first Aider:

  • Manager Sign:

  • Worker Sign:


  • Name:

  • Phone:


  • Medical Centre/A&E/Hospital:

  • Doctor:

  • Type of treatment provided:

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:

  • Toolbox Meeting held for:

  • Date/Time:

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.