Incident Report Incident Report Form This form is to be completed for any incident/accident/near miss that occurs during your work shift. Please ensure it is completed, signed and submitted to your manager as soon as practical after the incident. ABOUT THE INCIDENT INCIDENT ADDRESS: INCIDENT DATE: INCIDENT TIME: DESCRIPTION OF WHAT OCCURRED: INCIDENT RESULT: DID THIS INCIDENT RESULT IN AN INJURY TO A PERSON/S?: WERE THERE ANY WITNESSES TO THE INCIDENT: WITNESS DETAILS: ABOUT THE INJURED PERSON FAMILY NAME: GIVEN NAME: CONTACT PHONE NUMBER: GENDER: MALEFEMALE DATE OF BIRTH: OCCUPATION: INJURED PERSON’S INVOLVEMENT WITH WORKPLACE: HOME ADDRESS: ABOUT THE INJURY / ILLNESS DESCRIPTION OF INJURY OR ILLNESS: WHAT PART OF THE BODY WAS INJURED?: AS A RESULT OF THE INCIDENT WAS THE PERSON: Unconscious? Resuscitated? Fatally Injured? Hospitalised? IF HOSPITALISED PLEASE PROVIDE HOSPITAL DETAILS: ABOUT THE PRINCIPAL CONTRACTOR LEGAL NAME: TRADING NAME: CONTACT PERSON: CONTACT PERSON POSITION: ABN: BUSINESS PHONE NO.: BUSINESS EMAIL ADDRESS: MAIN BUSINESS ACTIVITY: STREET ADDRESS: ABOUT THE PERSON COMPLETING THIS FORM FAMILY NAME: GIVEN NAME: CONTACT PHONE NUMBER: WORK EMAIL ADDRESS: ARE YOU REPORTING THIS INCIDENT ON BEHALF OF ANYONE ELSE? Person Reporting Incident: Name: Position: Date: Signature:
