Title Page
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Type of Incident
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Conducted on
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Name of person filling in form
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Reported by:
- Officer
- Employee
- Contractor
- Visitor
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Their name/s:
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Their email address/es:
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Their phone number:
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The workflow
Particulars of Incident
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Date:
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Location:
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Name of Injured person:
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Address of injured person:
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Occupation of injured person:
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Age of injured person:
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Phone of injured person:
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Email address of injured person:
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Length of Employment (if a staff member):
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Was a drug test performed
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What was the result:
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Particulars of Incident (Describe what happened, add photos or take a picture of a drawn diagram)
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Nature of Injury (What part of the body is affected and how, take pictures if applicable and permission given):
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Property Damage (What damage was caused and how):
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Analysis (What do you think caused or contributed to the incident)?
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Prevention (What action has been taken to prevent a reoccurrence)?
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Have all preventative actions been reviewed by management and implemented?
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Name of first Aider:
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Manager Sign:
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Worker Sign:
Witness/s
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Name:
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Phone:
Treatment:
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Medical Centre/A&E/Hospital:
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Doctor:
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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
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WorkSafe advised by:
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Date/Time:
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Investigation conducted by:
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Date/Time:
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Hazard/Risk Register updated by:
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Date/Time:
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Toolbox Meeting held for:
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Date/Time:
