Type of report
*
Injury / Illness
Near Miss
Incident
Incident Details
Date of incident
*
-
Month
-
Day
Year
Date
Time of Incident
*
Hour Minutes
AM
PM
AM/PM Option
Location of Incident
*
Brief Description of Incident, injury or near miss
*
Person/s involved
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Person involved Type
Guest
Visitor
Employee
Contractor
Other
Employer
Employer Contact
Witness 1 Details
Witness 1 Name
First Name
Last Name
Witness 1 Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Witness 1 Email
example@example.com
Witness 1 Type
Guest
Visitor
Employee
Contractor
Other
Witness 2 Details
Witness 2 Name
First Name
Last Name
Witness 2 Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Witness 2 Email
example@example.com
Witness 2 Type
Guest
Visitor
Employee
Contractor
Other
Police Details
Did the Police attend?
*
Yes
No
Police Contact
Detail what happened
Include area and task, equipment, tools, and people involved
*
Nature of the injury
Please Select
Abrasions, scrapes
Amputation
Broken bones
Bruise
Burn (heat)
Burn (Chemical)
Concussion
Contusion / crush injuries
Dermatitis
Dislocation
Electric shock
Foreign Body
Inflammation
Internal Injuries
Insect bite / sting
Laceration
Poisoning
Superficial injury
Sprains / Strains
Indicate body location of Injury:
Treatment
If treatment was received, please indicate type of treatment and place of treatment
First Aid
*
Yes
No
First Aid treatment:
Hospital Inpatient
*
Yes
No
Hospital Name & Address:
Medical Centre
*
Yes
No
Medical Centre Name & Address:
Involved Vehicle Details
Was a vehicle involved?
*
Yes
No
Vehicle Make & Model:
Vehicle Colour:
Vehicle Registration:
Involved Plant/Equipment Details
Especially if any damage was sustained to the plant
Completion / Signatures
Person Involved Signature
*
Date Signed:
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: