Incident Type
Incident Number
Injury/Illness
Security Breach
Assets Damage/Loss
Community/Heritage
Non-Compliance / Process
Legal Requirement
Client Requirement
Seam Requirement
Other
Process
Environment
Health
Quality
Safety
Heritage
Other
Non-compliance Description
Regulatory Authority
Source Of Obligation
Fire
Environmental
Hazards
Near Miss
Non work related
Details
Location
Reported by:
Reported to:
Supervisor Responsible
Name
Employee ID
Relationship to incident (e.g. Witness, Operator, Injured Person, Complainant)
Injured?
Burns / Scals
Concussion with intracranial injuries
Contusions with intact skin surfaces
Dermatitis
Dislocation
Effects of radiation
Effects of toxic substances
Electric shock
Fracture
Heart and vascular disease
Infectious and parasitic disease
Internal injuries
Open wound
Sprains and strains
Thermal stress
Superficial injuries
Inflammation
Other
Internal energy
External energy
Contaminant
Treated by:
Treatment given:
Lost Time Injury (LTI)
Disabling Injury (DI)
Medical Treatment Injury (MTI)
First Aid Injury (FAI)
Description
Brief Description
Detailed Description
Immediate Actions Taken After Incident
SLAMS Available?
SLAMS Collected?
Client Name
Reported to client?
Investigation
Investigation Leader
Leading up to incident - what happened?
Following the incident - what happened?
Backup documentation
Inadequate comms
Inadequate Training
Inadequate Supervision
Inadequate PPE
PPE Failed to protect.
Mistake: Lack of knowledge, unintentional
Slip/lapse of attention
Violation: Intentional deviation
Other
Explanation
Equipment contributing factors
Work area contributing factors
Exists but not followed
Exists but inadequate
Exists but unrealistic / impractical
Exists but not known
Does not exist
Formal risk assessment inadequate (JSA, SLAM etc)
Root cause summary
Corrective Actions
Action title
Action Description
Assigned to
