Health & Safety Investigation Form
Type
*
Hazard
Near Miss
Incident (Someone was hurt)
Person Involved
Name of person
*
Full Name Please
Age
*
Contact Phone Number
-
Area Code
Phone Number
Group name
*
School, Church, Contractor, Staff
First Aid Details
Types of injury
*
Bruising
Scratch / Abrasion
Cut / Laceration
Burn / Scald
Dislocation
Internal
Foreign body
Fracture
Amputation
Chemical Reaction
Other
Where was the injury
E.g. left arm, lower back
Treatment given
Did {nameOf} go to the Doctor or Hospital?
No
Yes
Where did they go?
Was first aid given
*
Yes
No
First Aiders Details
First Aiders Name
*
First Name
Last Name
Reporters Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Details
Date of incident
*
/
Year
/
Month
Day
Date Picker Icon
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
15
30
45
Minutes
AM
PM
AM/PM Option
Area of camp where the incident accord
*
I.E. Soccer Field, Pool, Giant Swing, Dinning room
Describe what happened
*
Contributing Factors
Guarding
Defective tools or equipment
Hazardous arrangments
Unsafe conditions
Unsafe Design
Environmental conditions
Operations without authority
Disabled safety devices
PPE Not used
Non-use of lockout systems
Unsafe positioning
Distraction / fooling around
Other
Analysis - What caused the incident to happen
*
Upload Image of injury
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Describe The Hazard
*
Upload Image of Hazard
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Chance of near miss, incident or hazard recurring
Daily
Weekly
Monthly
6+ Monthly
One-off
Was there damage to any property or equipment?
*
Yes
No
Damage
What was damage?
*
Please give short description of what happened and then full in the correct form
Upload Image Damage
*
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