Information

  • Document No.

  • Entity

  • Tenement

  • Conducted on

Details

Details of Incident/Accident

  • Project Manager

  • Supervisor on Site

  • Person Completing this Report

  • Person Who Reported Incident/Accident

  • Witness(es)

  • Person(s) Involved

  • Employer of Person(s) Involved

  • Location of incident - if at site
  • Location of incident - Approximated

  • Insert Photo of Accident/Incident Scene

  • Insert Photo of Accident/Incident Scene

  • Insert Photo of Accident/Incident Scene

  • Insert Photo of Damages

  • Insert Photo of Damages

  • Insert Photo of Damages

  • Enter Drawing - Summary of Circumstances (

  • Date and time of Incident

Nature of Incident/Accident

  • Injury Free Event

  • Lost Time Day - Illness

  • First Aid - Fit for Work

  • Medical Treatment Required

  • Property Damage

  • Environmental

  • Complaint / Breach of Security or Safe Work Practises

  • Near Miss

  • Enter Description of Circumstances

Potential Cause of Incident/Accident

  • Breach of Existing Policies and Procedures

  • No Existing Procedure

  • Procedure/Equipment Not Fit for Procedure

  • Equipment Failure

  • Environmental / Work Area Hazard

  • Lack of Awareness / Competence / Skill

  • Miscommunication

  • Provide Details

Immediate Action / Responses Taken

  • Enter a Description of Response to Incident/Accident

  • Enter a Description of Proactive Corrective Action Taken

Remedial Action / Recommendations

  • Risk Register Update

  • Documentation Revision/Update

  • Communication with Employees

  • Training

  • Communication - External

  • Review of Contract

  • Consider Termination

  • Enter a Brief Description of Recommendations

Record

  • I confirm that I have recorded this incident and all actions as accurately as possible

  • Enter Name and Sign

  • Add location
  • Time when report completed

Email to safety@mcreasy.com.au as soon as practical

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.