INCIDENT REPORT

ALL INCIDENT REPORTS MUST BE COMPLETED WITHIN 24 HOURS OF NOTIFICATION

Current location

Enter address manually

Address of incident

PARTICULARS OF THE INCIDENT

Date of Incident:

Time of Incident:

Date Reported:

Reported To:

Attach any images of the incident

THE INJURED PERSON

Injured person name:

Injured Person Position:

Injured Person Age:

Injured Person Phone Number:

Length of Employment:

Injured Person Length of Employment:

Injured Person Address:

DETAILS OF THE INCIDENT

RISK CATEGORY

DESCRIBE HOW THE INCIDENT OCCURRED AND WHAT CAUSED THE INCIDENT:

How bad was it?

How bad could it have been?

What is the chance of this happening again?

Name of witness

WAS THERE ANY PROPERTY, EQUIPMENT OR ENVIRONMENTAL IMPACTS?

WHAT IMMEDIATE ACTION WAS TAKEN AND/OR TREATMENT GIVEN?

Was first aid administered?

Yes No Not Applicable

Did employee go to hospital?

Yes No Not Applicable

Was there any time lost due to this incident?

Yes No Not Applicable

If there was any time lost due to this incident, how many hours were lost?

INVESTIGATIVE ACTION TAKEN

Was the task usually performed by the injured person?

Yes or No & Provide reasons...

Was the task carried out in accordance with normal instructions?

Yes or No & Provide reasons...

Was the person trained in the task?

Yes or No & Provide reasons...

What safety instructions were given immediately prior to doing the task?

Yes or No & Provide reasons...

Were there any other factors involved?

Yes or No & Provide reasons...

CORRECTIVE/PREVENTATIVE ACTION TO BE TAKEN:

By Whom:nWhen:nCompleted:

Acknowledgements

HEALTH AND SAFETY REP SIGNATURE

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HEALTH AND SAFETY REP NAME:

HEALTH AND SAFETY REP DATE SIGNED:

SAFETY CO-ORDINATOR SIGNATURE

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SAFETY CO-ORDINATOR NAME:

SAFETY CO-ORDINATOR DATE SIGNED:

MANAGER SIGNATURE

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MANAGER NAME:

MANAGER DATE SIGNED:

INJURED PERSON SIGNATURE

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INJURED PERSON NAME:

INJURED PERSON DATE SIGNED:

WITNESS SIGNATURE

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WITNESS NAME:

WITNESS DATE SIGNED:

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