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