• Incident Report Form

    Accidents and Hazards

    USE THIS FORM TO REPORT ANY WORKPLACE INCIDENT, INJURY, ILLNESS, NEAR MISS, DANGEROUS OCCURRENCE, OR HAZARD. ALSO USE THIS FORM TO RECORD FIRST AID TREATMENT RECEIVED.

  • 1. DETAILS OF THE PERSON INVOLVED IN THE INCIDENT OR REPORTING THE HAZARD
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  • IF CONTRACTOR / EMPLOYED BY CONTRACTOR (STATE NAME OF CONTRACTOR).
  • IF CONTRACTOR / EMPLOYED BY CONTRACTOR OR IF VISITOR / AUDIENCE MEMBER (STATE ADDRESS).
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  • 2. DETAILS OF THE INCIDENT OR HAZARD
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  • :
  • DESCRIBE THE TASK BEING PERFORMED, SEQUENCE OF EVENTS, UNEXPECTED EVENT, OR HAZARD: THE NATURE AND SERIOUSNESS OF THE HAZARD.
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  • 3. DETAILS OF THE INJURY / ILLNESS – IF ANY
  • E.G. STRAIN, CUT, BURN.
  • SPECIFY LEFT / RIGHT WHERE APPROPRIATE.
  • WHAT ACTION / EXPOSURE / EVENT DIRECTLY CAUSED THE INJURY / ILLNESS?
  • WHAT OBJECT / SUBSTANCE / CIRCUMSTANCES WERE DIRECTLY INVOLVED?
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  • 4. INITIAL TREATMENT
  • RETURNED TO WORK?
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  • 5. NAME OF PERSON COMPLETING THIS REPORT
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  • COMPLETE SECTIONS 6 AND 7 WITH MANAGER / SUPERVISOR

    6. CAUSES(S) OF INCIDENT / HAZARD
  • IF OTHER PLEASE SPECIFY.
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  • 7. ACTIONS RECOMMENDED / TAKEN TO PREVENT RE-OCCURRENCE OR REMOVE HAZARD
  • ACTION TAKEN TO PREVENT RE-OCCURRENCE / REMOVE HAZRD (AND WHO BY / WHEN BY?).
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  • 8. MANAGER / SUPERVISOR
    I CONFIRM THE DETAILS OF THE INCIDENT REPORTED AND AGREE WITH THE RECOMMENDATIONS MADE.
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  • A COPY OF THIS FORM SHOULD BE RETAINED BY YOU AND A COPY PROVIDED TO THE PRODUCTION MANAGER. A SEPERATE WORKERS COMPENSATION CLAIM FORM AND WORKCOVER MEDICAL CERTIFICATE IS REQUIRED FOR COMPENSATION CLAIMS.
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