Employee Incident/Hazard/Near Miss
Was this an Incident or an Accident?
*
Please Select
Incident
Hazard
Near Miss
Date
*
-
Month
-
Day
Year
Date Picker Icon
Who is this report in relation to?
*
First Name
Last Name
Report completed by Name
*
First Name
Last Name
Date of incident/Hazard
*
-
Month
-
Day
Year
Date Picker Icon
Time of incident/Hazard
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Location
*
Cause,(Environmental, Behavioural, etc )
*
Please Select
Behavioural
Environmental
External Person
Other
if other please explain
How Likely is it for this to reoccur
*
Please Select
Rare
Unlikely
Likely
Very likely
Will happen frequently
Description of Incident/Accident
*
Download Picture Here
Browse Files
Cancel
of
Employee Explanation/Notes
*
Witnesses (were there any and if so do you have statements?)
*
Please Select
Yes
No
Witness/Witnesses Names
Was Medical assistance required?
*
What immediate containment measures can we put in place to prevent re occurrence?
*
Have you notified someone?
Yes
No
Not Required
Who was notified?
Please upload any relevant photos
Browse Files
Cancel
of
Support Officer responsible
*
Please Select
Marguerita@diverselearning.com.au
Kat@diverselearning.com.au
Meg@diverselearning.com.au
Amelia@diverselearning.com.au
Belinda@diverselearning.com.au
Kaia@diverselearning.com.au
Kari@diverselearning.com.au
Heather@diverselearning.com.au
Submit
Should be Empty: