Incident Report Form- Ready Movers

Incident Report Form- Ready Movers

This form MUST be completed and submitted within 24 hours. Sections A to D MUST be fully completed and signed off by the person involved (or by supervisor if worker is incapacitated).
Depot:*
Section A:
Type of incident

Incident (Resulting in injury and property damage)Incident (Resulting in injury and no property damage)Incident (Resulting in property damage and no injury)Near-hit situationHazard identifiedEnvironmentalIssue
Reported by

First NameLast Name
Section B- Employee Details (Person Involved)
SurnameGiven NamesClassification
Phone Number
Please enter a valid phone number.
Witness (if any)

NameBusiness/ Home addressPhone Number
Section C- Incident/ injury details
Date and time of incident or injury or when symptoms were noticed or diagnosed

DayMonthYear
Date
Hour MinutesAM/PM Option
Where was individual at time?

On duty/course of workTravelling on dutyTravelling to/from workOther
Where did the incident occur? Describe the exact location
Give full details of the incident – preceding events, what happened, the type of task being done, any hazards involved, and protective equipment being used.
Upload Photos

Cancelof
Task frequency (tick one):

Routine task eg., performed daily, weeklyUnusual task, performed less often
Section D- Injury or Illness Details (if applicable)
Type of first aid given: Did any absence from work result in
the loss of at least a full working day? Yes No No. of Absent Hours
Type First Aid given
Did any absence from work result in the loss of at least a full working day?

YesNo
Number of absent hours
Body Location (tick appropriate answers)
Head

EyeEarNoseMouthTeethFaceSkull
Trunk

NeckHipChestStomachGroinButtocksBack
Internal

HeartLungsOther
Arm

LeftRightThumbFingersKnuckles
Hand

LeftRightThumbFingersKnuckles
Leg

LeftRightKneeLower legAnkle
Foot

LeftRightGreat ToeOther toesHeel
Nature of injury/disease (tick appropriate answers)
Nature of injury/disease (tick appropriate answers)

AbrasionBruise/crushingFractureConcussionPunctureLacerationAmputationBiteHeart attackHearing lossForeign bodyDislocationSprainStrainHerniaExposureBurnScaldRashPoisoningTraumatic shockElectric shockPsychosocialOther
Incident Cause (Mechanism)

Striking againstStruck byCaught inStepping onStumblingSlippingTrippingFallingLiftingBendingTwistingStressPushingPullingJumpingIngestionAbsorptionInhalationOther
Breakdown Agency (Object, Substance,Circumstance)

VehiclePower toolAnimalObjectsBuildingFurnitureHeat stressNoiseMobile plantOther toolsMaterialsEquipmentStructuresSurfacesSunburnStressOther
Signature
Should be Empty:

Incident Report Form- Ready Movers

Section A:

Section B- Employee Details (Person Involved)

Section C- Incident/ injury details

Section D- Injury or Illness Details (if applicable)

Body Location (tick appropriate answers)

Nature of injury/disease (tick appropriate answers)