Incident / injury report form   						 

Please print clearly and tick the correct box
Status:	   Employee	   Contractor	   Other	
Outcome:	   Near miss	   Injury		
1. DETAILS OF INJURED PERSON	
Name:	 Phone:  (H)	 (W)		
Address:	 Sex:	      M	       F	
	 Date of birth:		
	 Position:		
Experience in the job:	 (years/months)	
Start time:	    am         pm	
Work arrangement:	   Casual	   Full-time	    Part-time	   Other	
2. DETAILS OF INCIDENT	
Date:		Time:		
Location:		
Describe what happened and how:		

3. DETAILS OF WITNESSES	
Name: 	 Phone: (H)	 (W)		
Address: 		
		
4. DETAILS OF INJURY	
Nature of injury (eg burn, cut, sprain)		
Cause of injury (eg fall, grabbed by person)		
Location on body (eg back, left forearm)		
Agency (eg lounge chair, another person, hot water)		
5. TREATMENT ADMINISTERED	
First Aid given	   Yes	   No	
First Aider name:		
Treatment:		
Referred to:		

SECTION 6-9 MUST BE COMPLETED BY EMPLOYER	
	
6. DID THE INJURED PERSON STOP WORK ?	
   Yes		   No	If yes, state date:	 Time:		
Outcome:	
   Treated by doctor		   Hospitalised	    Workers compensation claim	
   Returned to normal work	   Alternative duties	   Rehabilitation	
7. INCIDENT INVESTIGATION (comments to include causal factors):	

		
		
8. RISK ASSESSMENT	
Likelihood of recurrence:		
Severity of outcome:		
Level of risk:		
9. ACTIONS TO PREVENT RECURRENCE	
Action	By whom	By when	Date completed	

10. ACTIONS COMPLETED	
Signed (Manager):	 Title:		
	 Date:		
    Feedback to person involved 	 Date:		
11. REVIEW COMMENTS	
OHS committee / staff meeting:		
Reviewed by site Manager (signed):	 Date:		
Reviewed by Health & Safety Rep.(signed):	 Date: