Inspection

Details of person involved

Name

Address

Date of Birth

Phone number

I identify my gender as

Division

Position
Details of near miss / incident / injuries

Type

What happened? Describe what has occured

How did it happen? Describe how this may have have happened.

Immediate action? Were there any immediate actions taken to prevent this happening

What happened? Describe what has occurred.

How did this happen? Describe how this may have happened.

Immediate action? Were there any immediate actions taken to prevent this happening.

What happened? Describe what has occurred.

How did it happen? Describe how this may have happened.

Immediate action? Were there any immediate actions taken to prevent this happening.

What happened? Describe what has occurred.

How did it happen? Describe how this may have happened.

Immediate action? Were there any immediate actions taken to prevent this happening.

Location where incident happened
Date incident happened
Date incident reported

Injury details. If an injury occurred, what part of the body was injured? (Eg cut to lift wrist; break to right leg; N/A etc)

First Aid / Medical Treatment

Was first aid provided

First aid provided by

Date

Did the injured person stop work

Did the injured person attend medical care (eg doctor or hospital)

Name of Doctor / Medical Centre

Name other type of medical care

Witnesses

Were there any witnesses

Name of witness

Phone number of witness

Name of witness

Phone number of witness

Signatures
Sign here
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.