Accident to a Person, Incident or Observed Hazard Reporting Form
To report an incident, please provide the following information
PART A - To be completed by the person reporting accident, incident, or hazard.
SECTION 1 - PERSON REPORTING
Person is who reporting this incident?
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Email
Your role/relationship to the incident/injured person.
Date and time incident/hazard was reported:
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Date and time when incident/hazard actually occurred:
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
SECTION 2 - REPORT TYPE
REPORT TYPE
Description of incident.
*
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SECTION 3 - INJURED PERSON INFORMATION
Who was involved in the Incident? Please provide the first name and last name of the injured person.
First Name
Last Name
Contact Details of injured person
Mobile Phone
Email Address
Date of birth of injured person and other important information
Date of Birth
Any other information medical or otherwise.
Address (optional)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
SECTION 4 - INCIDENT / HAZARD DETAILS
Location where accident occurred / hazard is located.
Full name and phone number/emails of witnesses to incident/hazard.
Was a report of the incident notified to any one else?
SECTION 5 - INJURY / ILLNESS DETAILS
Please provide details of nature of injury/illness (eg: cut, bruising, sprain)
Please provide details of injury to body and location (eg: back, right shoulder)
Treatment applied to injured person
Do you want us to get in contact with you? (person reporting incident)
Yes
No
Further General Comments
Please provide your signature below
Date this report submitted to Risk Manager/Supervisor
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