Incident Report
Initial Details
To be completed in the event of a worker being involved in or witnessing any incident that has resulted in an injury to a person that requires or required more than basic first aid.
Was an injury suffered?
Yes
No - (if No, you must complete an "Near Miss Report" not this "Incident Report")
Reference
State
Please Select
QLD
NSW
VIC
TAS
NT
SA
WA
Who had the incident?
Who was involved in the incident?
Employee
Non-Employee
Personal Details
First Name
Last Name
Address
Phone Number
Email
example@example.com
Who Reported The Incident? Same as the person who had the incident?
Yes - Continue to next section
No - Enter Reporter Details below
Reporter Details
First Name
Last Name
Address
Phone
Email
example@example.com
About the Incident
Where did it happen?
Site Address
Site Reference (Customer Name)
When did it happen?
-
Month
-
Day
Year
Date
Time
Hour Minutes
AM
PM
AM/PM Option
What happened?
First Aid
Was first aid given? If yes, provide details.
Were there any pther person/s involved in the incident? If yes, provide details.
Were there any witnesses to the incident? If yes, provide details.
Has the incident site been made safe? If yes, provide details of action taken.
Photo of damage, hazard and or injury
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