Incident report form checklist
Use this form only if there is an injury or a workcover reportable accident. this page is to completed by the employee (with team leader’s assistance if required) and handed to the team leader as soon as practicable after the incident (any of the above) this form may be completed by a third party on behalf of an injured employees who is unable to do so.
What does this form include?
This form contains 30 sections:
AFFECTED EMPLOYEE WILL BE PROVIDED WITH A COPY OF THIS REPORT AS ACKNOWLEDGMENT OF NOTIFICATION OF TH
Date and Time of Incident Date
Date and time work ceased by employee Date
Date and time incident was reported to Team Leader Date
Team Leader
Task at Time of Incident
Experience in this task (Years & Months)
Describe the location of the incident
Type of Accident (Manual Handling, Fall, Impact, etc.)
People or Objects Involved (Machinery, other person, tools etc.)
Type of Injury (Bruising, strain, fracture etc.)
Body Part(s) Effected (Head, foot, hands, lower back, etc)
Employee Signature
Witness To Incident
Where possible this investigation is to be jointly undertaken by the employee, Teamleader and OH&S Re
Identify all the hazards applicable as the causing factors of this Accident, Injury, Near Miss. (Select all applicable)
Image, if 'Other' is selected
RISK MANAGEMENT
In your opinion what action should be taken to remove or minimise the hazards (include the action already taken)
What actions are recommended to prevent a recurrence of this incident? ( Please indicate time frame, estimated cost, completion date and persons responsible)
Photographs where applicable
Investigation performed by
OH&S Representative if applicable
Agree with information supplied by the involved
- Agree with information supplied by the involved
What is the overall likely level of the severity of the incident?
- What is the overall likely level of the severity of the incident?
What is the chance of such injuries recurring?
- What is the chance of such injuries recurring?
I have sighted this form and checked that all relevant details are provided and consistent.
I have classified this as an
- I have classified this as an
Add signature
Additional notes
Use this template