PWM-WHS008 Incident Report

• Completed by

• Report conducted on

  Date

• Person involved in the incident

• Incident location
  Address

• Date & time of incident

  Date

• Treatment details (if required):

  First aid

  Medical treatment

  Hospital

• Short description of incident:

• Is the worker able to return to work?

  Yes

  No

  N/A

• Why can't the worker able to return to work? explain in detail

• Do does the injured person(s) accept fault for this incident?

  Yes

  No

  N/A

• If no, why not? explain how it was caused by another party in detail

• Name:

• Gender:

• Date of birth (DoB):

• Employer:

• Occupation:

• Signature:

  Sign

Witness 1

• Name:

• Employer:

• Statement (explain the series of events leading up to the incident and explain what you witnessed):

• Signature:

  Sign

Witness 2

• Name:

• Employer:

• Statement (explain the series of events leading up to the incident and explain what you witnessed):

• Signature:

  Sign

• Name

• Date

  Date

• Signature

  Sign