ACCIDENT/INCIDENT REPORT and INVESTIGATION FORM

Date report is being made:

This form is to be used for ALL accidents, or near misses, whether an injury occurred or not
PART A: ACCIDENT / INCIDENT REPORT FORM
TO BE COMPLETED BY PERSON INVOLVED
(or by supervisor or if person is incapacitated then by nearest relative)
Please complete within 24 hours of the accident. If the accident caused, or could have caused, serious
injury or property damage.
1: INFORMATION ABOUT THE PERSON MAKING THE REPORT
Full Name: Gender: Date of Birth
Male Female

Status:
Employee Volunteer Member Contractor Visitor Other
Occupation: Contact telephone number

Are you currently YES NO If yes, please provide employer details

employed?

Name of employer:

Address:

What type of event is this?

Where did it occur?

Have you already reported the accident / incident / near miss? YES NO

If YES, who did you report it to? Name Date

Reported

2: WHAT PART OF THE BODY WAS AFFECTED (tick appropriate answers)

Head Trunk Internal Arm Hand Leg Foot
Eye Neck Heart Left Left Left Left
Ear Hip Lungs Right Right Right Right
Nose Chest Systemic Shoulder Thumb Knee Great
Toe
Mouth Stomach Upper Fingers Lower Leg Other
Arm Toes
Teeth Groin Elbow Ankle
Face Back Forearm Thigh
Skull Multiple Wrist

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 ACCIDENT/INCIDENT REPORT and INVESTIGATION FORM
3: NATURE OF INJURY (tick appropriate answers)
Abrasion Puncture Heart Attack Sprain Burn Traumatic Shock
Bruise Laceration Hearing Loss Strain Scald Electric Shock
Fracture Amputation Foreign Body Hernia Rash Psychosocial
Concussion Bite Minor Cuts Allergy Chemical
Aggravation of previous injury or medical condition, or other injury not already specified. (describe)

4: AGENCY OF INJURY (tick)

Vehicle Buildings Mobile Plant Structures
Power tools Furniture Other tools Surfaces
Animal/Insect Heat Stress Materials Sunburn
Biological agent Chemicals Equipment Stress
Objects Ionising radiation

Signature: Date:

PART B: INVESTIGATION FORM

TO BE COMPLETED BY THE MANAGER AND/OR DELEGATED WITHIN 48 HRS OF
NOTIFICATION

1: PROBABLE CAUSE/S OF ACCIDENT / INCIDENT (tick appropriate answers)

Inadequate Instruction Fault Of Plant Or Equipment Poor Storage Weather
Inadequate Workspace Equipment Unavailable Poor Access Terrain
Assistance Unavailable Lack Of Attention Incorrect Method Work Practices
Other (Describe)

2: DESCRIBE THE ACCIDENT / INCIDENT

3: RATE THE POTENTIAL SEVERITY OF THE ACCIDENT / INCIDENT

(e.g. what could have happened?)
Low Moderate High Severe
(eg first aid treatment) (e.g. medical Treatment) (eg ambulance or other (eg death or severe
emergency services) disablement)

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 ACCIDENT/INCIDENT REPORT and INVESTIGATION FORM
4: PREVENTION OF ACCIDENT/INCIDENT RECURRENCE
Describe what action is planned or has been taken to prevent a recurrence of the accident/ incident, based on
the key contributing factors (Please print)
Immediate action taken

Suggested long term action

IS TRAINING REQUIRED? REHABILITATION

Induction YES NO Is required
Task specific YES NO Is not required
Area specific YES NO Unknown as yet
Time Off Work Required.

5: ADMINISTRATION
Investigation undertaken by supervisor or delegated.

Print name: Date investigation completed:

Signature:

A copy of this report must be provided to the person making the report. The original must be retained by
HSE Manager
copy provided to person making report Date

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