Workplace Incident / Injury / Illness Report Form

Report Number
(HSE use only)

Page 1

Use this form to report all workplace incidents, injuries and work related illnesses whether or not they result
in time off work near misses included.
All reports are to be advised asap - to your supervisor / manager and hse manager (0409 694 324)

TYPE OF INCIDENT

                       

EMPLOYEE DETAILS

 

REPORTING DETAILS

INCIDENT DETAILS

FULL DESCRIPTION OF INCIDENT (please attach description)

INCIDENT DETAILS Diagram or Photos ONLY (please attach description above if required)

INJURY AND TREATMENT (HSE Manager or delegate to complete)

Status of injured person
           
       

Classification of Incident
         
         

INJURY DETAIL

Select the box that reflects most accurately

INJURY NATURE LOCATION ON BODY CAUSE OF INJURY

ACKNOWLEDGEMENT

  PERSON REPORTING INCIDENT SUPERVISOR / MANAGER HSE MANAGER