Health & Safety Incident Report
Notifiable incidents, significant events, and near misses.
This report relates to:
*
Injury/Harm
Property damage
Near miss
1. Incident details
Incident date
*
-
Day
-
Month
Year
Date
Incident time
Hour Minutes
AM
PM
AM/PM Option
Incident location
*
Date reported
-
Day
-
Month
Year
Date
Person involved
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Region
Postal Code
Email
Phone Number
*
Format: (000) 000-0000.
Date of birth
-
Day
-
Month
Year
Date
2. Near miss details
Describe the near miss incident.
2. Injury/harm/damage details
Type of injury
*
Bruising/Strain/Strain
Break/Fracture/Dislocation
Cut/Scratch/Abrasion/Laceration
Foreign body
Burn/Scald
Chemical reaction
Electrical
Internal
Other
Injured area of the body
Notes
Outcome
Return to work
Alternative duties
Time off
Other
Damage to property
Details of the material or property damaged:
Nature of the damage:
Object/substance causing damage:
3. Accident details
Describe what happened (if this was a vehicle accident please upload a drawing of the accident scene to the form using the upload field below):
*
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
What caused the accident?
*
How serious could the incident have been?
*
Minor
Serious
Very serious
How often is this likely to happen again?
*
Not often
Occasionally
Often
4. Prevention
What action has or will be taken to stop another accident like this happening?
5. Treatment & investigation of accident
Type of treatment given:
Name of person giving first aid:
Doctor/Medical centre/Hospital
Incident investigated by:
Date
-
Day
-
Month
Year
Was WorkSafe notified after consultation with a Manager?
Yes
No
Date
-
Day
-
Month
Year
Save
Submit
Should be Empty: