Hazard & Incident Report Form
Use this form the report hazards, incidents, near misses, injuries and illness.
Report Type
*
Please Select
Hazard
Near Miss
Illness or Disease
Incident with Injury
Incident without Injury
Date Time Location
Indicate the date and time the hazard or incident occurred.
Date & Time
*
-
Day
-
Month
Year
Minutes
AM
PM
AM/PM Option
Site Location
*
The site or venue or general area the incident or hazard occurred.
Exact Location
*
Describe the exact location where the incident or hazard occurred.
Reporter
Please record your details for follow-up.
Reporter Name
*
First
Last
Reporter Role
*
Contact Details
*
Please provide a phone number or email
Incident Detail
Incident Description
*
Describe the incident in detail.
Hazard Detail
Hazard Description
*
Describe the incident in detail.
Hazard Status
Fixed or Resolved
Hazard Isolated
Unresolved/No Action Taken
Describe how and when the hazard was resolved.
*
Describe any measures taken to isolate the hazard until it can be resolved.
*
Injured Person and Treatment
Record information about the injured person and their treatment.
Is the Reporter also the Person Injured?
*
Yes
No
Full Name
*
First
Last
Role
*
Contact Details
*
Please provide a phone number or email
Injury Position
*
Head
Stomach
Chest
Back
Shoulder Left
Shoulder Right
Arm Left
Arm Right
Hand Left
Hand Right
Leg Left
Leg Right
Foot Left
Foot Right
Injury and Treatment Description
*
Detail the injury or disease, part of the body affected and the treatment type provided, the name of the person/s who provided treatment (i.e. first respondent, first aid, doctor etc.) and any other related information.
Supervisor
In the event of an incident or hazard a supervisor must be notified. Note the supervisor on duty and how were they notified.
Supervisor Name
*
First
Last
Supervisor Notification Method
*
Please Select
In Person
Phone Call
Text or Slack
Email
Witness
Please record full name and contact for up to three witnesses.
*
Rows
Full Name
Contact Number
Witness 1
Witness 2
Witness 3
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