Are you reporting a serious harm incident? Yes No Who is reporting the incident? First Name Last Name Email Phone (###) ### #### Details of the incident Date MM DD YYYY Time Hour Minute Second AM PM Location where the incident happened Type of injury or damage Being hit by objects or things Biological factors Body Stressing Chemicals or substances Tools or equipment Heat, radiation, or energy Hitting objects with part of body Psychosocial (Includes mental health) Sound or pressure Slips/trips/falls Vehicle incidents OOS or RSI Other (please state) Who was involved? Person 1 First Name Last Name Phone (###) ### #### Person 2 First Name Last Name Phone (###) ### #### Person 3 First Name Last Name Phone (###) ### #### Other people involved? Property Damage What was damaged? Nature of damage What happened? Description of the near miss or incident Analysis - What caused the incident? How serious is the incident? Minor Serious Very Serious How often is the incident likely to happen? Never Rarely Occasionally Often What actions can be taken to prevent the incident happening again in future? Witnesses Witness 1 First Name Last Name Phone (###) ### #### Witness 2 First Name Last Name Phone (###) ### #### Witness 3 First Name Last Name Phone (###) ### #### Witness 4 First Name Last Name Phone (###) ### #### Medical Treatment Type of treatment First aid administered by First Name Last Name Clinic/hospital where injuries treated Name of doctor/clinician First Name Last Name Worksafe Has worksafe been advised? Yes No Date MM DD YYYY Time Hour Minute Second AM PM Other notes Anything else to add? Thank you for reporting this incident. We will be in contact in due course
