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INCIDENT REPORT FORM .WEB PDF Flipbook PDF
INCIDENT REPORT FORM .WEB PDF
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IPDFA INCIDENT REPORT FORM
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 Surname:
First name(s):
Position: Managers Name: Address: Telephone number (landline): Telephone number (mobile): Email address:
Incident details (completed by person involved) Date of incident:
Time of incident:
Description of incident: (in your own words, what happened?)
Location of incident:
ALL RIGHTS RESERVED IPDFA POLEPRO 2008
DOB:
IPDFA INCIDENT REPORT FORM
Name of witnesses to the incident Name:
Contact:
Name:
Contact:
Name:
Contact:
ALL RIGHTS RESERVED IPDFA POLEPRO 2008
IPDFA INCIDENT REPORT FORM
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
Yes
No
Yes
No
(If yes, provide their name and contact details)
Details of any damage Did any damage to property occur?
(If yes, provide details of the damage)
Other details Were the Police involved?
(If yes, provide details of the officers attending)
ALL RIGHTS RESERVED IPDFA POLEPRO 2008
IPDFA INCIDENT REPORT FORM
Was the State Safety Regulator (WorkCover) informed?
Yes
No
Is this a workers compensation related incident?
Yes
No
Authorisation of corrective action
Name
Signature
Date
ALL RIGHTS RESERVED IPDFA POLEPRO 2008