Scribd
Upload
316 views

TEMPLATE - Incident Report Form

The document provides instructions for completing an incident report form for any work-related injuries, illnesses, or near misses at the XYZ Company. It states that all such incidents must be reported immediately and an incident report form completed by the first aid attendant. It also notes that occupational health and safety legislation requires employers to record all work-related injuries. The form is used to document details of the incident, injury sustained, treatment provided, and work status of the injured employee.

Uploaded by

Zia Malik
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
316 views

TEMPLATE - Incident Report Form

The document provides instructions for completing an incident report form for any work-related injuries, illnesses, or near misses at the XYZ Company. It states that all such incidents must be reported immediately and an incident report form completed by the first aid attendant. It also notes that occupational health and safety legislation requires employers to record all work-related injuries. The form is used to document details of the incident, injury sustained, treatment provided, and work status of the injured employee.

Uploaded by

Zia Malik
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
You are on page 1/ 3

Incident Report Form

The XYZ Company is committed to providing and maintaining a safe and healthy workplace environment, and ensuring
all our work practices are conducted safely.

All injuries/illnesses and incidents sustained at work must be reported immediately so that appropriate treatment can be
given, the causes investigated, and control measures implemented as soon as possible to prevent a similar accident from
occurring in the future. Near misses that did not cause injury must also be reported.

Occupational Health and Safety legislation in all states require employers to record all injuries sustained at work, in a
Register of Incidents/Accidents.

Instructions

 An Incident Report Form must be completed for all employee and contractor Incidents/Accidents, regardless of how
insignificant the injury may appear to be.
 This is NOT a Workers' Compensation Claim Form.
 The Incident Report Form is to be initiated by the attending First Aider, who should complete all
Sections 1 – 6 and sign the form where appropriate as soon as possible after the Incident/Accident.
 The First Aid Attendant should immediately forward the completed form to the relevant line manager.
 The form should be reviewed and, if appropriate, an incident investigation commenced within 24 hours and Incident
Investigation Report Form completed.
 The original copy should be held centrally and filed alphabetically in the Register of Incidents/Accidents. The form
must be kept for a minimum of seven (7) years.
 If the injury results in a Workers' Compensation Claim, a copy of the Incident/Accident Report should be attached to
the Workers' compensation Claim Form.
 If the incident is significant or serious, the relevant State OH&S Authority must be notified (refer to Notifiable
Incidents in the Incident Reporting and Investigation section of the OH&S Procedure Manual). The CML OH&S
department may also need to be notified by fax (refer to 'Critical Events' in the Incident Reporting and Investigation
section of the OH&S procedure Manual).

NOTE: Only when injury results in medical expenses or lost time should the employee be advised to complete a
Workers' Compensation Claim Form (available through Administration).

 All Incident Report Forms must be reviewed by ???? (Include name of person responsible).
INCIDENT REPORT FORM
Injury/Illness Property Damage Near Miss (dangerous occurrence, no injury or
property damage)
Location: (DC) _________________________________ Ref No: ________________________________
Date Received by OHS Coordinator/HR Department: ________________________
Section 1. – Personal/Employment Details
Full Name: __________________________________________ Employee No:_______________________________________
Address: ____________________________________________________________________ Postcode:__________________
Date of Birth:_________________________________________ Gender M / F
Occupation: _________________________________________ Time in this Job:_____________________________________
Department:_________________________________ Supervisor/Line Manager: _____________________________________
Employment Status: Full Time Part Time Casual Contractor/non-Employee
If not an employee of company XYZ, state name of employer: ____________________________________________________

Section 2. – Occurrence of the Incident


Date of Incident: _________________________ Time of Incident: ________________ Date Reported: _________________
Work Activity being performed at the time of the Incident: _______________________________________________________
Exact Location of Incident:_________________________________________________________________________________
Describe in full, the circumstances of the incident (provide attachment if needed)_____________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Names and contact details of witnesses:______________________________________________________________________
_______________________________________________________________________________________________________

Section 3. – Type of Injury


Strains/Sprains Amputation Animal/insect bite Puncture wound
Lacerations/Abrasions Hearing Loss Hernia Soft tissue injury
Heat
Contusion (Bruise) Foreign body Welding flash
stress/Exhaustion
Burns - heat Dermatitis (Skin rash) Dental Pain/Tenderness
- chemical Respiratory irritation Twist Disease
- other Toxic reaction Whip lash Swelling Multiple
Fracture/Dislocation Internal Crush injury Other (Specify)

Part of Body Injured: Left Right Multiple


Chest Arm upper Head/Face Back upper Foot Finger (Specify)__________
Abdomen Arm lower Scalp Back middle Ankle Toe (Specify)____________
Hip Elbow Nose Back lower Other _______________________
(Specify)
Genitals Wrist Ears Leg upper _______________________________________
Groin Hand Eyes Leg lower _____________________________________________
Circulatory Shoulder Neck Knee _______________________________________
Is it a recurring injury? Yes No

Section 4. – Property Damage


Description of damage :____________________________________________________________________________________
_______________________________________________________________________________________________________

Section 5. – Treatment
Was any Treatment Required? Nil First Aid Referred to Doctor Sent to Hospital
Ambulance called Returned to Work
First Aid Attendant:_______________________________________________________________________________________
First Aid Treatment Given:__________________________________________________________________________________
_______________________________________________________________________________________________________
Section 6. – Work Status following injury
Return to normal duties Left work – Home/Hospital/Doctor Alternative Duties
Is it likely that person may miss one complete shift? Yes No
ALTERNATIVE DUTIES ALTERNATIVE DUTIES
Hours:________________________________________ Type of duties given: ________________________________
Rehabilitation Required: Yes No _________________________________________________

A copy of this report has been provided to the Employee Yes No


Supervisor/Line Manager Signature: ____________________ Employee Signature: _________________________________
Incident Investigation Required? (refer to guidelines in OHS Procedure Manual) Yes No
If yes, Supervisor/Line Manager responsible_________________________________
Notification of Incident Required? Yes No Date Achieved: __________________________

You might also like