Incident Report Form Sub-Contractor Employee

Incident Report Form – Sub-Contractor Employee

1. Details of Person Involved/Injured

Name

Address

City

State

Zip Code

Phone / Home:

Mobile Number:

Gender:

Male

Female

Other

Date of Birth:

Year of Class:

2. Year of Class

Type of Incident:

Date & Time of incident

Reported to:

Type of injury sustained:

Injury location (part of body):

Description of incident:

Names of witnesses:

Please attach written statements from any witnesses

Form completed by:

Name

Signature

Sign Here

Date

3. First Aid

Was first aid treatment applied to the injured person at the site?

Yes

Description of First Aid administered:

Injured person referred to:

Doctor

Ambulance

Hospital

Nil

Have next to kin been notified?

Yes

Not Required

Notified Time

Please indicate injury location with arrows

Right FRONT VIEW Left

Left BACK VIEW Right

Other external agencies involved:

Police

QFRS

Other

Other external agencies involved: - Other