Incident Report Form

This form is to be used to report all injuries, illnesses, or near misses, whether an injury occurred or not, and to document the investigation.
Please complete within 24 hours of the incident.

Required fields in the form are marked with an *

SECTION A: TO BE COMPLETED BY PERSON INVOLVED

DETAILS OF PERSON INVOLVED

DETAILS OF THE INCIDENT

PART OF BODY AFFECTED

DETAILS OF THE INCIDENT/INJURY/NEAR MISS

SECTION B: TO BE COMPLETED BY THE SUPERVISOR & THE PERSON INVOLVED WITHIN 48 HOURS

This is an extremely important section as the aim of the incident investigation is to identify preventative action that will avoid recurrence.

DETAILS OF THE CAUSE OF THE INCIDENT/INJURY/NEAR MISS

PREVENTION OF INCIDENT RECURRENCE

DETAILS OF PROFESSIONAL SERVICES INVOLVED

LOCAL ADMINISTRATORS DETAILS

Thank you for completing the online Incident Report Form.
By submitting this form you accept responsibility to the actual events and outcomes possibly attained from this incident as a true statement.