Incident and Hazard Report Form
v2.2
Purpose. Used by any worker to report an injury, near miss, hazard, property damage or vehicle incident so that it can be recorded, investigated and closed.
1.When to use this form
Complete this form for any injury, illness, near miss, hazard, chemical exposure, vehicle incident or property damage at any site or event location. The form must be completed on the day of the event by the person involved or the person who observed it, and given to the department lead.
2.First actions
Before completing this form, make the area safe, give or obtain first aid, and tell the department lead. For a serious injury call emergency services first. Do not clean up or move equipment involved in a serious incident until the department lead has seen it.
3.Completing the form
Describe what happened in plain words, in order, with times. Name any witnesses. Describe the tools, chemicals, vehicles or stock involved. Record any first aid given and whether medical treatment was sought.
4.What happens next
The department lead will enter the report in the Incident and Hazard Register, investigate the causes and record corrective actions. The General Manager reviews every incident and decides whether the regulator must be notified. The person who reported the incident will be told the outcome.
5.Privacy
Personal and medical information on this form is used only to manage the incident and meet legal obligations, and is stored in the confidential safety file.