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Incident Report Form

The person reporting is to follow the Incident and Accident Procedure. Identify the WHO, WHERE, WHEN, WHAT, WHY and HOW questions with regard to the incident. Complete this report as soon as practicable.

Section A: Details of the incident/near miss

Person reporting incident(Required)
Classification(Required)
DD slash MM slash YYYY
Time of occurence(Required)
:
Location
Client Address(Required)
Client Representative(Required)

Section B: Initial Investigation

Treatment (if injured)

Section C: External Notification (if required)

Authorites notified

Section D: Witnesses

Name and Contact Number (add multiple by clicking on the + icon)
Witness 1 Name
Witness 1 Phone
 

Section E: Full Description of Incident

Section F: Investigation Recommendations

Outline recommended corrective action/s (i.e. solution/s) to prevent the recurrence of the incident eg. Engineering solution? Substitution? Safe Work Procedures etc.
Recommendations (add multiple by clicking on the + icon)
Recommendation
Person to action
Completion date
 

Section G: Attachments e.g. photos, witness reports etc - please tick and upload below

I will upload the following attachments
Drop files here or
Max. file size: 128 MB.

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