Incident Report
This Incident Report form should be used to record any incidents, accidents, injuries, illnesses and near misses that occur on site.
Report date and time:
*
-
Day
-
Month
Year
Date
24 Hour Time - HH:MM
Date and time when incident occurred:
*
-
Day
-
Month
Year
Date
24 Hour Time - HH:MM
Please select the type of incident:
*
Please Select
Incident
Accident / Injury
Property Damage
Near-miss
Safety Observation
Uno Loco Job Number (Please see Uno Loco Staff for this number)
If number is known
Event Name:
*
Incident reported by:
*
First Name
Last Name
Email (If we need to contact you for follow up questions)
*
example@example.com
Phone Number
-
Country Code
-
Area Code
Phone Number
Reporting as:
*
Please Select
Uno Loco Team
Supplier
Contractor
Venue Team Member
Visitor / Guest
Incident Location (Please provide specific details):
*
Incident details (Please provide as much detail as possible)
*
Upload supporting photos:
Upload photos (Max 5 under 10mb)
Drag and drop files here
Choose a file
File types: pdf, jpg, jpeg, png, heic
Cancel
of
Further Comments
Acknowledgement
*
I certify that to the best of my knowledge the above information is true and correct.
Submit for Investigation
Uno Loco Investigation Use only.
Name of Investigator
First Name
Last Name
Investigation Date and Time:
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Day
-
Month
Year
Date
24 Hour Time - HH:MM
Was this a notifiable event (i.e. does this need to be notified to Worksafe?)
Yes
No
What was the cause of this incident?
What can be done to prevent this occurring again?
Is any further action / followup required? If so, please explain:
Complete Report and Submit
Should be Empty: