Incident/Near-miss Report

Job Address: *

Street address *

Suburb *

City *

Postcode *

Job Description *

First Name *

Last Name *

Company Name *

Date and time of incident/near-miss: *

Name of person (injured or observer), description of incident/near-miss, type of injury (if any). How did it happen? (briefly). *

Add photo (optional):

Browse

First aid applied? *

YesNo

Corrective action taken? *

YesNo

Hazard register reviewed/updated? *

YesNo

Does this incident require a WorkSafe notification? *

YesNo

Should this incident be investigated by your company? *

YesNo

Is this incident the subject of a toolbox talk? *

YesNo

Signature: *

Draw signature|Type signatureClear

Date: *

Comments