ACCIDENT / INCIDENT REPORT FORMACCIDENT / INCIDENT REPORT FORMFILL IN ALL FIELDS WITH AN ASTERISK (*). If you are not confident in completing this form, please contact your supervisor or the Safety OfficerBusiness Name & LocationNameFirst NameLast NameEmailPhone NumberEmployment Status Full time Part Time Casual Contractor OtherOtherJob Description / OccupationDate of BirthDetails of the manager to whom the Accident / Incident / Near-miss was reportedManager NameFirst NameLast NamePositionPhone NumberTYPE OF ACCIDENT / INCIDENT / NEAR-MISSSelect the appropriate description Near miss Property damage Attended Company medical centre Attended hospital emergency department Electrical First aid - returned to work Admitted to hospital OtherOther - describe the incidentType of Injury Fracture Sprain Burn Strain Cut OtherOther - Type of InjuryDate and time of event as it occurred:Was First Aid administered Yes NoIf First Aid was administered - by whom?Date and time when event was reportedMechanism of Incident / Injury / Disease Slips, trips and falls Near miss Heat radiation or electricity Sound or pressure Hitting objects with body part Body stressing Chemicals and other substances Biological factors OtherMore informationAgency of Incident Machinery & fixed plants Powered equipment,tools & appliances Chemicals & chemical products Mobile plant & transport Materials& substances Non-powered hand tools / appliances / equipment Heights OtherOther - Agency of IncidentName of witnessFirst NameLast NameFirst NameLast NameBRIEF DESCRIPTION OF THE ACCIDENT / INCIDENT / NEAR MISS In your description select 1 of 4 figures and describe the location of the injury. Add as many details pertaining to the event. If an injury was sustained please indicate the exact area of the body. Use the diagram above to assist you with the location e.g. rear right leg above the knee.Add supporting images/photos, videos and/or audio filesBrowse Files Description(s) of uploaded file(s)DateTick box to confirm I certify that the above information is true and correct.SubmitACCIDENT / INCIDENT / NEAR MISS INVESTIGATIONThe following fields are to be completed by a supervisor or the Safety OfficerWas this accident/incident/near-miss reported to Workcover? Yes NoDid the person stop work Yes NoIf yes, What date?Returned to workLost time (days)Details of investigationOutcomes and any short and long term actions proposed to prevent a recurranceFeedback to person/s involved completed Yes NoReview required Yes NoIf yes, date of that reviewThis accident / Incident / Near Miss is Under Investigation Closed OtherOther -The accident / Incident / Near Miss is
