Incident Report Submission.

Fill in details below and click submit to submit Incident.

User Email: | Company:

Incident Type: Loss Time Injury Medical Treatment First Aid No Injury Near Miss Fatality

Date Occurred:

Site Name:

Name:

Notes:

Enter Incident Description:

Enter Involved Users:

Incident Location:

Department Involved:

Incident Category/Classification: None Lightning Damage to Property Fire Machines Theft, Security Breach Vehicle Occupational Disease Sabotage Infrastructure (Steps, Rails, Roads, walkways, etc.) Electricity Fall of Ground

Was this incident / accident picked up with Risk Assessment? No Yes

Should the risk of this hazard be assessed? No Yes

Was anyone injured? No Yes

Describe HOW the injury occurred:

Select the affected Body Part: None Eye Internal Hand Arm Multiple Trunk Finger Leg Foot

Select the Effect on the Person Involved: None Fracture Concussion or Wounds Electric Shock Burns Sprains & Strains Amputation Multiple Asphyxiation Poisoning Unconsciousness

Select the Expected Period of Disablement: 0 Days 1 - 14 Days 14 + Days 3 + Months Permanent Disablement Fatal

Describe the machine/process involved or type of work performed:

Select Applicable General Agency: None Fall Pinched Electrocution Struck By Collision Struck Against Falling Object Handling Trip or Slip

Select Applicable General Environmental Agency: None Dust Chemical Heat Vapour Noise Fumes Gas

Select an Unsafe Act: NA Distracted, testing, horseplay Taking unsafe position Operating at unsafe speed Unsafe loading, placing, mixing Working on moving or unsafe equipment Safety regulations ignored Failure to use P.P.E Using equipment unsafely Making safety devices inoperative Operating without authority

Select an Unsafe Condition: NA Lightning Inadequate guarding Unguarded Defective tools, equipment or substances Unsafe clothing Hazardous arrangements Poor lighting Poor floor conditions Poor ventilation Unsafe design or construction

Select a Personal Factor: NA Lack of knowledge or skills Improper behaviour or motivation Physical/mental attribute

Select a Job Factor: NA Unsafe conditions Inadequate work standards

Describe Immediate Action Taken:

Full Name of Investigator:

Media URL: