Free Incident Report Template 05Free Incident Report Template 05
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Incident Report
Particulars of incident:
Date:

Time:

Location:

Type of incident (please circle below):
Injury

Illness

Environmental

Notifiable event

Reported by:

Phone:

Role in the event:

Email:

Other:

The injured person:
Name:
Age:

Address:
Phone:

Witness(s):
Name:

Phone:

Name:

Phone:

Name:

Phone:

Describe the incident: (space overleaf for diagram if needed)

Describe any illness or injury: What part of the body is affected and how?

Describe any property damage: What damage was caused and how?

Analysis: What do you think caused or contributed to the incident?

Prevention: What action has been taken to prevent a reoccurrence?

Have all preventative actions been reviewed by the Event Management Committee, and implemented?
Yes
No
Signature:

Date completed:

Treatment:
A & E Hospital:

Doctor:

Type of treatment provided:
Notification and investigation WORKSAFE PHONE: (0800) 030-040 (24 hours)
Worksafe NZ advised by: