Solargain: Form 25 - Incident Report Form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Details of Incident:

• Date of incident:

  Date

• Time of Incident:

  Date

• Date reported:

  Date

• Time Reported:

  Date

• Witness Name:

• Witness Contact:

• Location of incident:
  Address

• Incident Type: (Select One)

  Injury

  Near Miss

  Property Damage

  Theft

  Other

• If Incident Type is "Other", please give details:

• Incident description or details of property damage:

• Photo/s of Incident (if applicable):

  Media

• Completed by:

• Date Completed:

  Date

If Property Damage:

• If Panels (Stock) list serial numbers:

• Photo of damaged property: (If Applicable)

  Media

• Cause of damage:

• Is a re-charge invoice required? (If Yes => Please forward to Corporate for sign off / Action)

  Yes

  No

  N/A

• Re-charge invoice details:

• Party to be invoiced:

• Invoice Number:

If Injury:

• Part of body injured:

  Select Head Leg Multiple Trunk Arm Eye Feet Neck Hands Ears Toes Fingers Front Rear Left Side Right Side Other

  • Head
  • Leg
  • Multiple
  • Trunk
  • Arm
  • Eye
  • Feet
  • Neck
  • Hands
  • Ears
  • Toes
  • Fingers
  • Front
  • Rear
  • Left Side
  • Right Side
  • Other

• If "Other", Please explain:

• Nature of injury:

  Select Amputation Fracture Dislocation Burn Sprain/Strain Laceration Concussion Disease Infection Foreign Object Electric Shock Other

  • Amputation
  • Fracture
  • Dislocation
  • Burn
  • Sprain/Strain
  • Laceration
  • Concussion
  • Disease
  • Infection
  • Foreign Object
  • Electric Shock
  • Other

• If "Other" Please explain:

• Agency of injury:

  Select Machinery People Powered Hand Tool Manual Hand Tool Lifting Equipment Transport Environment Static Equipment Other

  • Machinery
  • People
  • Powered Hand Tool
  • Manual Hand Tool
  • Lifting Equipment
  • Transport
  • Environment
  • Static Equipment
  • Other

• If "Other", Please explain:

• Type of incident:

  Select Injury Near Miss Property Damage Theft Other

  • Injury
  • Near Miss
  • Property Damage
  • Theft
  • Other

• If "Other"Please explain:

• Injured Workers Details:

• Full Name:

• D.O.B:

• Address:
  Address

• Occupation:

• Phone Number/s:

• Gender:

  Yes

  No

  N/A

• How long employed with company:

• Supervisor's Name:

• Office Location:
  Address

• Medical Attention required:

  Yes

  No

  N/A

• Description of occurrence (If Injury or near miss the worker involved to complete this section).

• Photo Accompanying Description:

  Media

• Supervisor / Manager comments:

• Signature of Supervisor / Manager:

  Sign

• Date Signed:

  Date

Incident Review:

• Work Safe Notification Required?

  Yes

  No

  N/A

• WorkSafe Notification required By (Date / Time).

  Date

• Data Time of actual WorkSafe Notification:

  Date

• Work Cover Notification Required?

  Yes

  No

  N/A

• WorkCover notification required By (Date / Time).

  Date

• Data Time of actual WorkCover Notification:

  Date

• Insurance Company Notification Required?

  Yes

  No

  N/A

• Data Time Insurer Notified:

  Date

• Investigation Required:

  Yes

  No

  N/A

• Investigation Assigned to:

• Incident entered on register:<br>

  Yes

  No

  N/A

• Incident notification form uploaded to MYOSH?

  Yes

  No

  N/A