Incident Report

To be completed for ALL incidents and accidents where an injury has or could have resulted.

Work Location: *

Organisation Facility In the CommunityClient Home Other

Date *

Time of incident *

Client First and Last Name *

Outcome *

Hazard Near MissIncident First Aid

Employee Information

Staff First Name

Staff Last Name

Gender *

MaleFemale

Phone Number *

Email Address

Address of incident: *

Details of witnesses (if any):

Incident Information

Please provide the following into details of incident below*

1)Activity engaged in at time of incident:

2)Exact location of person at time of incident:

3) Describe how and what happened (please give full details & include a diagram, if appropriate. Use a separate sheet if necessary. Please include car registration number if reporting a Motor Vehicle Accident). It can also include paragraphs.

1)Activity engaged in at time of incident: *

2)Exact location of person at time of incident: *

3) Describe how and what happened (please give full details & include a diagram, if appropriate. Use a separate sheet if necessary. Please include car registration number if reporting a Motor Vehicle Accident). It can also include paragraphs.

Immediate Actions Taken: Question: What immediate actions were taken following the incident? Explanation: Describe the steps that were taken right after the incident was identified. This can include first aid, evacuation, shutdown of machinery, etc. *

Incident Photos/ Incident Sheet *

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Details of injury Action if applicable: *

Details of injury Person

Psychological/Stress/Bullying/Harassment Psychological/Stress/Workload/Organisation Hazardous Substance/Material Biological Agency Entrapment in Equipment/Machinery Strike/Struck by Equipment/ Machinery

Specific: More Details of injury

Please attach photo

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Treatment administered if required:

Name of First Aid Attendant

First Aid Attendant Signature

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Your Name: *

Your Signature *

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