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Incident and near-miss reportSaved

Incident and near-miss report

Report number
Company
Project or site
Date of incident
Time of incident
Exact location
Date reported

Incident type

People involved

NameRole or tradeCompanyContactInvolvement

What happened

Injuries and treatment

NameInjury or illnessBody partTreatment givenTreated bySent to hospital

Immediate actions taken

Contributing factors

Corrective actions

ActionPerson responsibleDue dateCompleted

Reported to

Supervisor notified
Name and time
Regulator notifiable (yes / no)
Insurer notified
Other parties notified

Notifiable incidents must be reported to the work health and safety regulator in your state or territory immediately, and the scene preserved until told otherwise.

Reported by

Name
Signature
Date

Reviewed by

Name
Signature
Date