Incident, Injury & Hazard Report Form
ABN: 73 114 531 636 | CRICOS Code: 02869G | RTO No: 91256
Contain Confidential information
*
Yes
No
Person reporting the incident
*
Employee
Student
Contractor
Guest
Full Name
*
First Name
Last Name
Student ID
Phone Number
*
Email
*
example@example.com
Department
Job Title
Supervisor
Supervisor Email
example@example.com
Company Name
Incident Type:
*
Incident – With Injury
Incident – Without injury
Near Miss
Hazard
Description of Incident / Hazard
*
Including details, e.g. specific location, level, room, etc.
Date and time of Incident
/
Day
/
Month
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Date Reported
*
-
Day
-
Month
Year
Date
Injured Person
*
Employee
Student
Contractor
Guest
Name of Injured Person
First Name
Last Name
Email
example@example.com
Phone Number
Level of Treatment:
*
Report only
First Aid
Medical Treatment
Intend to Seek Medical Treatment
Lost Time Injury
Nature of Injury:
*
Cut
Abrasion
Bruising
Sprain
Burn
Fracture
Crush
Allergic reaction
Dislocation
Other
Body Location of injury (Indicate location of injury on the diagram):
Description of Illness / Injury:
Specific task being performed at time of Incident / Injury:
Description of Treatment Provided:
Name of First Aider or Treatment Provider:
Name of treating Doctor:
First Aider or Treatment Provider or treating Doctor Phone:
Details of contributing factors:
Lack of or inadequate plant/equipment
Inappropriate or inadequate work environment
Lack of or inadequate procedures/instructions
Lack of or inadequate management/supervision
Inappropriate or inadequate work environment
Lack of or inadequate management system
Inappropriate actions and/or behaviour
Other
Cause of Incident / Hazard:
Risk Assessment
Consequence
*
Please Select
Minor
Moderate
Major
Severe
Likelihood
Please Select
Unlikely
Possible
Likely
Almost Certain
Corrective Action(s) - Control Type(s):
Elimination
Substitution
Isolation
Engineering
Administration
PPE
Corrective Action(s) Description:
Person Responsible:
First Name
Last Name
Action(s) Completed:
Yes
No
If No, target date for completion:
-
Day
-
Month
Year
Date
Signature of the person completing the form
Confirmation of close out of corrective action(s) by the General Manager
Report Status
Approved
Denied
General Manager
First Name
Last Name
Date
-
Day
-
Month
Year
Date
Signature
Submit
Should be Empty: