INCIDENT REPORT FORM To be completed in the event of a worker witnessing/being involved in any non-conformance, or an incident, or resulting, or potentially resulting, in an injury or an unsafe practice or a near hit. Personal details: Name First Last Date Of Birth Position: Managers Name: Address Street Address City AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d’IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Telephone number (landline): Telephone number (landline): Email Incident details completed by person involved Date of incident: Time of incident: : HH MM AMPM Description of incident: (in your own words, what happened?) Location of incident: Name of witnesses to the incident Phone Name First Phone Name First Phone Name First Details of injuries sustained Injured person’s name: Type of injury: Treatment received: Injured person’s name: Type of injury: Treatment received: Details of other persons involved Did the incident involve any other person? Yes No (If yes, provide their name and contact details) Details of any damage Did any damage to property occur? Yes No (If yes, provide details of the damage) Other details Were the Police involved? Yes No (If yes, provide details of the officers attending) Was the State Safety Regulator (WorkCover) informed? Yes No Is this a workers compensation related incident? Yes No What did we do at the time of the incident? Change to induction/toolbox Proposed? Taken? Change to ongoing training Proposed? Taken? Change to work procedure Proposed? Taken? Change to work environment Proposed? Taken? Equipment maintenances Proposed? Taken? Job re-design Proposed? Taken? Site clean up Proposed? Taken? Risk assessment review Proposed? Taken? Other preventative action Proposed? Taken? Corrective actions Describe what needs to be done Who is responsible? Date for completion Consultation Who did we consult with when deciding on the actions for the controls? Name Position Contact details (phone) This iframe contains the logic required to handle Ajax powered Gravity Forms.
