Hazard / Incident Report

Hazard / Incident Report Form

If the hazard or incident requires the attendance of emergency services, please call 000

If there is imminent danger to persons or property, the person recognising the danger must take steps to isolate the danger and restrict access / entry if necessary.
Your Details
Name:*
Company:*
Date & Time:*

DayMonthYearHourMinutesAM/PM Option

Hazard or Incident
What are you reporting?*

Safety hazardIncident resulting in injuryIncident resulting in damage to propertyNear miss incident

Nature of Hazard
Brief description of the hazard:
Describe the task, equipment, and tools involved. Add photos below if necessary.
Photo 1:
Photo 2:
Photo 3:
Please identify who / what is at risk:

Person(s)PropertyOther
Please describe the imaginable consequence of the hazard:

Please identify the severity of the potential risk to persons or property:

	1	2	3	4	5

1 is Mild, 5 is Extreme

Location of Hazard
Where is the hazard located:
Add photos below if necessary to identify the location.
Photo 1:
Photo 2:

Details of Injured Person
Are you making this report for an injury sustained by you, or another person?

MyselfSomeone else
If someone else, please provide their details below:
Name

First NameLast Name
Address

Street Address

CityState

Postcode
Is the injured person:

An employee of Block ConstructionsA contractorA volunteerA member of the general publicOther
Please advise which company you / the contractor is employed by:

Nature of Incident Resulting in Injury
Brief description of the incident that has occurred:
Describe the action or task being undertaken at the time of incident, and the resulting injury. Include photos below if applicable.
Photo 1:
Photo 2:
Photo 3:

Indicate the apparent severity of the sustained injury:

	1	2	3	4	5

1 is Mild, 5 is Extreme

Where did the incident occur:
Add photos below if necessary to identify the location.
Photo 1:
Photo 2:

Medical Attention
Is medical attention necessary?

NoYes, medical facility / GPYes, A&E DepartmentTo be determined
Name of Hospital (A&E):
Name of Medical Facility / GP:

Details of Damaged Property
Describe the property which has been damaged:
Who does the property belong to:

Block ConstructionsEmployeeContractorClient / Home OwnerMember of publicOther
Please provide the details of the owner of the damaged property:
Owner

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Postcode
Email
Mobile Number

Nature of Damage to Property
Brief description of the damage that has occurred:
Describe the action or task being undertaken at the time of incident, and the resulting damage. Include photos below if applicable.
Photo 1:
Photo 2:
Photo 3:

Near Miss Incident
Brief description of the incident resulting in a near miss:
Describe the action or task being undertaken at the time of incident. Include photos below if applicable.
Photo 1:
Photo 2:
Photo 3:

Action Required / Taken
Recommended action to eliminate the hazard / avoid a recurrence of the incident:
List any suggestions you may have for reducing or eliminating the problem.
Has this hazard / incident been reported to on-site management?

YesNo
On-site manager name:
Has action been taken to fix the hazard / avoid a recurrence of the incident?

YesNo
Please describe the action which has been taken:
Include whether this is a permanent or temporary solution. Upload photos below if necessary.
Photo 1:
Photo 2:

Declaration
I declare that all of the information provided within this form is true and accurate, written in my own words and to the best of my knowledge.
Signature of person completing form:

Clear
Should be Empty:

Hazard / Incident Report Form