Serious Incident / Accident Reporting Form

• Date Reported

  Date

• Date of incident

  Date

• Site/ Location

  Select

• Reported by

• Other People involved

• Incident Type

  Select Accident Incident Near miss Verbal abuse Physical abuse

  • Accident
  • Incident
  • Near miss
  • Verbal abuse
  • Physical abuse

• Description of events

• Was anyone injured?

  Yes

  No

  N/A

• Please Complete Page 2 (Personal Accident/injury)

• What immediate Corrective actions (if any) were applied?

• What caused the event?

Findings And Root Cause - (H&S committee member or Site Manager to complete)

• Name of Investigator

• What follow up questions need to be asked?

• What is the Root cause of the event?

Corrective Actions

• What longer term Solutions need to be implimented

• Person assigned to Corrective actions

• Date Action to be completed by

  Date

• Date Corrective Action Closed

  Date

• Signed by designated Safety Manager

  Sign

• Signed by CEO

  Sign

• Signed by person who completed Incident Report

  Sign

Notification

• Hazard register

  Yes

  No

  N/A

• Staff Notified

  Yes

  No

  N/A

• 3rd Parties notified

  Yes

  No

  N/A

• HSWA (Worksafe) Notified

  Yes

  No

  N/A

• Please describe the injury details

• What part of the body was affected?

• Was 1st aid administered straight away?

  Yes

  No

  N/A

• What 1st aid was administered

• Did you seek Medical help after injury such as going to Dr or Hospital?

  Yes

  No

  N/A

• Does Worksafe need to be notified?

  Yes

  No

  N/A

• Further Questions or Comments

• Personal Accident investigated by:

• Signature

  Sign

• Date

  Date