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Accident/Incident report
Accident/Incident report
Complete the below Accident/Incident report form after any workplace accident.
Incident
Candidate details
Name
*
First
Last
Address
*
Address2
Gender
*
Male
Female
Date of birth
*
MM slash DD slash YYYY
Work details
Place of work
*
Length of employment (weeks/months)
*
Accident (A) and Incident (I) information
Date of A/I
*
MM slash DD slash YYYY
Time of A/I
*
:
Hours
Minutes
AM
PM
AM/PM
Location
*
Date reported
*
MM slash DD slash YYYY
Accident and Incident details
Type of injury (please tick)
*
Aches/pains
Burn/scald
Chemical reaction
Laceration/cut
Bruising
Strain/sprain
Dislocation
Scratch/abrasion
Dental
Foreign Body
Other
Other (please specify)
Injured part of the body
*
Left
Right
No Injury
Description of what happened
*
What caused the accident/incident to occur?
*
Type of accident/incident?
*
Near miss
Illness
Injury
Severity of the accident/incident? (please tick)
*
Minor
Serious
Moderate
Very serious
Treatment details
What treatment was given? (please tick)
*
None
Doctor/Hospital
First Aid
Other (please specify)
Accident/Incident investigated by?
Name
*
First
Last
Date
*
MM slash DD slash YYYY
WorkSafe
Does WorkSafe need to be notified?
*
Yes
No
If yes, please provide details (who did you speak to, date, outcome etc)
What action has, or will, be taken to stop another accident/incident of this nature reoccurring?
Action and when?
*
Date completed
*
MM slash DD slash YYYY
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