Incident Report - Formstack

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Incident Report

Complete this form if you have an accident, injury or near miss.
A supervisor or witness should complete this form if the person involved is not able to do so.
This form should be completed and sent to the WH&S officer within 48 hours of the incident.
All fires, electrical shocks, spillages of or exposure to toxic substances, and failures of load bearing equipment or structures must be reported to the WH&S officer (ph: 3347 7929) immediately, even if there is no injury.

Details of person involved in the accident, incident or near miss

Name

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Postcode

Phone

Email

Date of birth

Category

Staff Student Contractor Visitor

Accident/Injury/Near miss Details

Date and time of accident/injury/near miss

:

Location

Type of injury

Part of body affected

How did the accident/injury/near miss occur?

Medical attention given by:

First aid Doctor Hospital Paramedic Not needed or not applicable

Name

First Name

Last Name

What first aid was administered?

What drugs were administered?

Witness name or name of the person making the report on behalf of the injured person

First Name

Last Name

Email

Phone

Comments by WH&S Officer

Construction/maintenance problem?

Yes No

Was prevention reasonably practicable?

Yes No

Were correct procedures followed?

Yes No

Human behaviour?

Yes No

Plant & equipment?

Yes No

Process of work?

Yes No

Low morale?

Yes No

Work area conditions?

Yes No

Lack of training?

Yes No

Other

Business Manager's approval

Date

WHS - has the problem been fixed?

If not, what further action will be taken?

Issues to consider:

Date follow-up completed

Name

First Name

Last Name