Incident record/reporting form 							Form 9

To be completed by the injured person or their manager.
Forward copy of report to work health and safety representative.

1.	Time and place of incident	
Location of incident:		Incident reported to:		
Date of incident:		Name of witness:		
Date incident reported:		Signature:		
		Position/title:		

2.	Incident details	
Outcome of incident/exposure:	

	
No injury:	Nil obvious injury		Near miss		Property/equipment damage		
	
Work injury:	Lost time		First aid		Medical treatment		Return to work		
	
Serious body injury:	Fatality		Hospital stay overnight or longer		Property/equipment damage		

What were you actually doing at the time?	

	
Describe what happened.	

	
Aggravation of an existing injury/illness?	Yes			No		
						
Property damage related to injury?	Yes			No		
	
Comments:		

Name:		Signature:		Date incident reported:		
	(please print)		

3.	Immediate action taken to control risk (to be completed by manager)	

	
	
Name:		Signature:		Date incident reported:		
	(please print)		

Incident record/reporting form (cont.) 					Form 9

4.	Details of injured/involved person	
Full name:		Position title:		
Department:		Payroll no:		
Address (if visitor):		Date:		

Type of employment:	Full-time		Part-time		Casual		Volunteer		

Were you trained in this task, for example use of equipment?	
Yes		Years:		Months:		Days:			Nil		N/A		

Training in the task (describe):	

Proportion of shift worked at the time of incident:	
Before start			1st half of shift			2nd half of shift			Overtime			Journey		

5.	Rehabilitation (to be completed if person was on a rehabilitation program at time of injury)	
	
Was the task a selected or modified task?	Yes		No			(if yes, comment below)	

	

6.	Description of injury	

	

7.	Close-out action	

	

			
Work health and safety representative
(signature)		Date