Incident Report Form

This Form is to be completed to ensure efficient and effective reporting of incidents and non-conformances. The
completed form MUST be forwarded to Malcolm Williams within 24 hours. Sections A to D MUST be fully completed and
signed off by the person involved (or by supervisor if worker is incapacitated) and by their immediate supervisor. Forms
submitted with insufficient data will be returned..

SECTION A:

Incident(No injury or property damage) Incident (Resulting in injury or property damage)*

Near-hit situation *Note - if property damage, do you think this may be an
insurance claim?
Hazard identified Environmental
Externally Reportable Incident reported to: Reported by:
Incident

SECTION B – EMPLOYEE DETAILS (PERSON INVOLVED)

Surname Given Names Classification

Department Job Reference Phone Number

Witness (if any) – Name, Business/Home Address, Telephone №

1.

SECTION C – INCIDENT/INJURY DETAILS

Date and time of incident or injury or when symptoms were noticed or diagnosed / / am/pm
Where was individual at time? On duty/course of work Travelling on duty
Travelling to/from work Other
Where did the incident occur? Describe the exact location

Give full details of the incident – preceding events, what happened, the type of task being done, any hazards involved and
protective equipment being used.

Task frequency (tick one): Routine task eg., performed daily, weekly Unusual task, performed less often

SECTION D – INJURY OR ILLNESS DETAILS (if applicable)

Type of first aid given:
Did any absence from work result in the loss of at least a full working day? Yes No № of Absent Hours
On this occasion initial treatments were given by (Please
number/order): Not applicable
Doctor
Names/details: [1] First Aid Officer
Hospital
Names/details: [2] Others

Body Location (tick appropriate answers)

Head Trunk Internal Arm Hand Leg Foot

Eye Neck Heart Left Left Left Left

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Ear Hip Lungs Right Right Right Right

Nose Chest Other Shoulder Thumb Knee Great toe
Mouth Stomach Upper arm Fingers Lower leg Other toes
Teeth Groin Elbow Knuckles Ankle Heel
Face Buttocks Forearm
Skull Back Wrist

Nature of injury/disease (tick appropriate answers)

Traumatic
Abrasion Puncture Heart attack Sprain Burn shock
Bruise/crushing Laceration Hearing loss Strain Scald Electric shock
Fracture Amputation Foreign body Hernia Rash Psychosocial
Concussion Bite Dislocation Exposure Poisoning
Other;
Describe:_________________________________________________________________________________________________

Incident Cause (Mechanism)

Striking against Stumbling Lifting Pushing Ingestion
Struck by Slipping Bending Pulling Absorption
Caught in Tripping Twisting Jumping Inhalation
Stepping on Falling Stress
Other;
Describe:_________________________________________________________________________________________________

Breakdown Agency (Object, Substance, Circumstance)

Vehicle Building Mobile plant Structures
Power tools Furniture Other tools Surfaces
Animal Heat stress Materials Sunburn
Objects Noise Equipment Stress

Employee (Person Involved: Name: Signed Date:

Supervisor Name: Signed: Date:

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SECTION E

Is it an externally reportable offence? Is an investigation required? Is an internal notification required

PREVENTATIVE MEASURES

Replace/repair equipment Provide training Use safer materials

Improve design Improve supervision install safety device

Clean up Establish/review procedures/policies Improve signposting

Consult with workers involved Notify All employees (Toolbox/Alert) Review PPE

Other, details
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SECTION F – SIGN OFF AND CLOSE OUT

Was the root cause satisfactorily determined? Were the recommended actions satisfactory?

Has a follow up audit been carried out to verify compliance and effectiveness of actions?

Name: Signed: Date:

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