ACCIDENT / INCIDENT REPORT FORMACCIDENT / INCIDENT REPORT FORM FILL IN ALL FIELDS WITH AN ASTERISK (*). If you are not confident in completing this form, please contact your supervisor or the Safety OfficerName of injured person/sFirst NameLast NameFirst NameLast NamePhone NumberEmployment Status Full time Part Time Casual Labour Hire Contractor OtherOtherJob Description / OccupationDate of BirthDetails of the manager to whom the Accident / Incident / Near-miss was reportedManager NameFirst NameLast NamePositionPhone NumberLocation of incident Production facility Farm Visitors Centre Farm Fresh Workshop OtherTYPE OF ACCIDENT / INCIDENT / NEAR-MISSType of Injury Fracture Sprain Burn Strain Cut Mental Health OtherSelect the appropriate description Near miss Property damage Attended Company medical centre Attended hospital emergency department Environmental Electrical First aid - returned to work Admitted to hospital OtherOther - describe the incidentOther - Type of InjuryPlease give as much detail as possible of the Location where the accident / incident occured.Date and time of event as it occurred:Was First Aid administered Yes NoIf First Aid was administered - by whom?First Aid treatment administered to patientDate and time when event was reportedMechanism of Incident / Injury / Disease Slips, trips and falls Near miss Heat radiation or electricity Sound or pressure Striking Body stressing Chemicals and other substances Biological factors OtherMore informationAgency of Incident Machinery & fixed plants Powered equipment,tools & appliances Non-powered hand tools / appliances / equipment Chemicals & chemical products Mobile plant & transport Materials& substances Heights OtherOther - Agency of IncidentName of witnessFirst NameLast NameEmailPhone/MobileFirst NameLast NamePhone/MobileEmailBRIEF DESCRIPTION OF THE ACCIDENT / INCIDENT / NEAR MISS Add as many details pertaining to the event. If an injury was sustained please indicate the exact area of the body using the chart above as a guide. Use the diagram above to assist you with the location e.g. rear right leg above the knee.Add supporting images/photos, videos and/or audio filesBrowse Files Description(s) of uploaded file(s)DateTick box to confirm I certify that the above information is true and correct.SubmitThe section below is to be completed ONLY by the safety OfficerFeedback to person/s involved completed Yes NoReview required Yes NoThis accident / Incident / Near Miss is Under Investigation Closed OtherOther -The accident / Incident / Near Miss isClosing RemarksFirst NameLast Name
