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Incident Report Form
Incident Report Form
Step
1
of
2
50%
Your Name
*
First
Last
I would like to report:
*
An Incident
An Accident
A Near Miss
Were you the person directly involved in the incident / accident / near miss?
*
Yes
No – I am reporting on behalf of someone else
Date the incident/Accident/Near Miss occurred
*
DD slash MM slash YYYY
Time the Incident/Accident/Near Miss occurred
*
:
Hours
Minutes
Where did the Incident/Accident/Near Miss occur?
*
Please give a description of the incident / accident / near miss
*
Did anyone (including yourself) sustain any injury as a result of the incident or accident?
*
Yes
No
Please provide details of any immediate action taken to ensure that the incident / accident or near miss does not happen again
Details of the injured party
Name of the person injured
First
Last
Date of Birth of the injured person
Address of the injured person
Street Address
Address Line 2
City
ZIP / Postal Code
Please describe the injury sustained
Please detail any initial treatment that the injured person received immediately after the injury was sustained.
Please detail any professional advise sought after the injury was sustained
Is time off work required as a result of the injury sustained
Yes
No
The injured party was not an employee
Witnesses
Did anyone else witness the incident / accident or near miss
*
No – only myself
Yes – There were other witnesses
There were no witnesses, I have only been told what happened
If there was another witness, please provide their name
If there was another witness, please provide their contact number (if Known)
