WPA Register of Injuries, incidents and near misses

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Details of Worker

• Name:

• Address

• Phone Number

• Email

• Occupation

Details of injury / incident

• Location / department in which injury / incident occurred

• Incident Date and Time

  Date

• Nature of injury / incident

• Cause of injury / incident

• Address of Workplace

• # Of Lost Days

• # of Lost Hours

• First aid attendant

• Details of first aid treatment

• Accident Investigation completed?

  Yes

  No

  N/A

• Was the incident witnessed ?

  Yes

  No

  N/A

• If so by who ?

• Results of investigation

• WorkCover compensation form lodged ?

  Yes

  No

  N/A

• Date lodged

  Date

• Register Entry completed by

• Date

  Date

• Employee Signature

  Sign

• Manager Signature

  Sign