INCIDENT INJURY & NEAR MISS REPORT FORM
The reason for investigating an incident or near miss is to determine: the cause or causes of the incident; to identify any risks, hazards, systems, or procedures that contributed to the incident; and to recommend corrective action to prevent similar incidents. An Incident Report Form must be submitted to Management within 24 hours of the incident occurring.
Please select one of the option that best describes your relationship with us :
Employee
Member
Visitor
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TYPE OF REPORT
Injury/Illness
Near Miss
Incident
Date
-
Day
-
Month
Year
Date
Time
Hour Minutes
AM
PM
AM/PM Option
Location
Brief description of Incident, Injury or Near Miss
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PERSON/S INVOLVED
Member
Guest
Visitor
Volunteer
Employee
Contractor
Name
First Name
Last Name
Phone Number
Format: 000 000 0000.
Email
Contractor
Employer
Employer Contact
Format: 000 000 0000.
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Did the police attend?
Yes
No
Contact Name
Phone Number
Format: 000 000 0000.
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Injury/Illness/ Near Miss/ Detail what happened – Include Area And Task, Equipment , Tools, and people involved
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Indicate type of injury sustained
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
Other
Indicate which part of the body is injured/affected?
Head
Face
Arm Left
Arm Right
Hand Left
Hand Right
Shoulder Left
Shoulder Right
Back
Foot Left
Foot Right
Other
Highlight the body part injured/affected
Describe
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Treatment
First Aid provided
None
First Aid Treatment
Hospital Outpatient
Hospital Inpatient
Doctor
Medical Centre
N/A
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Was there a vehicle involved ?
Yes
No
Was there property involved ?
Yes
No
Make
Model
Colour
Registration
Involved Property details
Incident Notifiable to WorkSafe Victoria
Yes
No
Name
The Barwon Heads Golf Club
Date
-
Month
-
Day
Year
Date
Submit
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