INCIDENT REPORT
To be completed at the time of the incident or by end of day (including any near miss).
Date of incident
-
Day
-
Month
Year
Date
Time of incident
Hour Minutes
Nature of incident
Injury to employee
Injury to public
Injury to club member/volunteer
Injury to Sub-contractor
Near miss
Damage to equipment or property
Environmental damage
Other
Location of incident
CYCSA Reception
CYCSA Bistro
CYCSA Kitchen
Marina East
Marina West
Slipway
Other
Exact location of incident
Weather Conditions (if applicable)
visibility/wind speed/gusts/significant wave height/raining etc.
Incident details
Who/What/Why/Where/When
Any damage
yes
no
Details of damage
Please include any serial numbers of components
Upload picture of damage: 1
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of
Upload picture of damage: 2
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of
Did incident occur on a vessel
Yes
No
Vessel Name
Vessel Registration number
Vessel make
Vessel length and beam
Crew members on board
Any injuries
Yes
No
First aid
Nil required
Treated by first aider
Required ambulance
Required hospitalisation
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Employer if Subcontractor
Name of person giving first aid
First Name
Last Name
First aid treatment provided
Description of first aid given
If a staff member will the person require time off work
Yes
No
N/A
Has the return to work coordinator been advised
Yes
No
Second person injured
yes
no
First aid
Nil required
Treated by first aider
Required ambulance
Required hospitalisation
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Employer if Subcontractor
Name of person giving first aid
First Name
Last Name
First aid treatment provided
Description of first aid given
If a staff member will the person require time off work
Yes
No
N/A
Has the return to work coordinator been advised
Yes
No
Witness
Yes
No
Witness details
First Name
Last Name
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Address of witness
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Second witness:
Yes
No
Name
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What caused the incident
What immediate action was taken
Is it safe to continue work activities (if no, contact management and await instructions)
Yes
No
Is this incident a notifiable incident• the death of a person• a ‘serious injury or illness’, or• a ‘dangerous incident’
Yes
No
Person notifying
First Name
Last Name
Notified to Department Name
Form of communication
Name of person completing form
*
First Name
Last Name
Suggested actions to mitigate this incident in the future
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date
*
-
Day
-
Month
Year
Date
Time
*
Hour Minutes
Signature
*
Continue
Continue
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