Template Information
To be completed within 24hrs of any workplace incident or injury.
Category: general
Template Questions
- Project:
- Location
- Name of person completing this report:
- Date and time of injury; Date
- Employee Name
- Relevant Training / Toolbox talk to the task being undertaken
- Accident/Incident Details
- Job title if not listed above
- Location of accident (please be specific)
- Nature of Incident or Injury
- Describe who, what, when,where, why and how injury occurred:
- Contributing causes of the Incident: (Inadequate training, Inadequate supervision. Employee not following proper safety procedures and instructions)
- Possible Cause or Causes of the incident: (Inadequate PPE, Not Paying attention to surroundings, failure to utilise safety equipment)
- What is the employee's current status if injured: Describe. ( Returned to work the next day, off of work do to injury, off of work do to restrictions, In hospital, etc.)
- Severity:
- Set out the time line for the incident
- Supervision details
- Date and Time when the employer was notified: Date
- Name & Signature of the injured party
- Witnesses 1
- Name and signature of the witness 1
- Witnesses 2
- Name and signature of the witness 2
- Witnesses 3
- Name and signature of the witness 3
- Where was the Medical treatment first provided?
- Injury Details if Applicable
- If you choose other please specify.
- Provider Doctor Details
- Part of Body injured:
- If so, what are they?
- What was the immediate action taken to correct the issue (how was this done):
- Who was the responsible party for correcting the issue:
- What is the long term action needed to correct the issue:
- Lessons Learned:
- Additional Information
- Is the above report a true reflection of the Accident / Incident