Incident Report Form
1. Use this form to report work-related incidents, dangerous occurrences or near misses.
2. If an injury has also occurred as a result of an incident, dangerous occurrence or near miss that this form is being used to report then the separate First Aid (Accident) Report Form should also be completed by the person (if adult) or by an adult on behalf of the person/student who has sustained the injury.
3. Complete this form immediately after the incident, dangerous occurrence or near miss.
4. Submit this form as soon as it is completed.
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Email *
Section 1 - About the Incident
What are you reporting? *
Required
When did it happen? *
MM
/
DD
/
YYYY
What time did it happen? *
Time
:
Where did it happen? *
Required
What happened?
Please describe the accident, incident, dangerous occurrence or near miss, etc. Include events that lead to it, details about equipment, substances or materials involved. *
Witnesses?
Name and contact details of anyone who witnessed the incident: *
Section 2 - About the Person(s) involved
Who was involved? Please give the names, role, staff number (if applicable) and contact details of all persons involved: *
What type of injury has been sustained? *
What treatment / first aid was provided? *
Was the injured person able to return to lessons / work straight afterwards? *
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