Title Page
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This report is to be filled in and handed to Qld Built Pty Ltd Site Manager within 24 hours of an Incident. This report is to record additional information not contained on the statutory incident reporting form that is to also be filled out for Notifiable Accidents and Incidents.
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Site conducted
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Conducted on
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Prepared by
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Location
Details of Person/s Involved
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Name
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Date of birth
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Address
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Phone number
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Employer
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Employer phone number
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Principal Contractor
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Principal Contractor phone number
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Site address
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Date of accident/incident
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Time of accident/incident
Accident/Incident Details
Injury and Treatment Details
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Indicate location of the injuries and the vital signs using the above template: Please add a photo for reference.
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Treatment Given
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Did the injured person receive an Ambulance?
Accident/Incident Details
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Activity and area in which the person was engaged at the time?
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Cause of injury?
Investigation Form
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Injured Person - Name
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Injured Person - Employer
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Injured Person - Contact number
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Report File Number
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Principal Contractor
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Details of Injury
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Date and Time of accident/incident
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Details of Accident/Incident
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Name of Witness
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Statement taken from Witness
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Witness contact phone number
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Were photographs taken?
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Was WHSQ contacted?
Did the Injured Person:
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Receive first aid
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Receive an Ambulance
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Return to Work
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Go home
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Go to the doctor
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Go to the hospital
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Other
Recommendations
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Recommendation 1
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Date Recommendation 1 to be completed
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Recommendation 2
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Date Recommendation 2 is to be completed
Received by Management
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We are committed to the Workplace Health and Safety of all the workers on our work sites and will implement and review these new procedures to ensure the risk of these accidents/incidents is reduced.
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Name
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Position
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Date
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Signature
