Incident Report
Incident Location/Site Name
*
Date
*
-
Day
-
Month
Year
Date
Names of Staff Involved
*
Jaron Archer
Maz Kara
Jacob Lundon
Fraser Hoffman
Kaja Stiehler
Callum Mower
Nico Burgos
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What type of Incident occurred?
*
Damage- Equipment or property damage
Security/Theft- Site accessed unexpectedly or something was stolen
Environment-Pollution or hazardous substance spill
Near Miss-something occurred but there was no harm caused
Injury- Someone was physically hurt
Illness-Work related illness e.g. heat stroke
Other
Cause of Incident- What was the main reason why this incident occurred
Please Select
Animals
Asbestos
Body Stress
Confined Space
Electricity
Dust-Other
Dust-Silica
Dust-Wood
Engulfed
Equipment-Failure
Equipment- Height
Equipment-Machinery
Equipment-Mobile Plant
Equipment-Tools
Fall from Height
Fall-Same level
Falling objects
Fire/Explosion
Harassment
Hazardous Atmosphere
Hazardous Substance
Health Issue
Infection/Disease
Lack of risk controls
Mental Stress
Noise
Person vs Object
Pressure Release
Slip/Trip
Structural Collapse
Suspended loads
Terrain
Traffic accident
Trench collapse
Underground/Overhead services
Vehicle
Vibration
Water/Liquid
Weather
Unknown
Other
What Treatment was applied
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First Aid- Performed on worksite
Medical Centre-Minor injury or illness
Hospital- Major injury or illness
Unsure- Im not sure what treatment was given
None-No treatment was required
What type of injury/illness
*
Allergic Reaction
Amputation
Bite/Sting
Bruising/Swelling
Burn
Concussion
Cut/Laceration
Dehydration/Heat Stroke
Dislocation
Eye injury/irritation/vision loss
Fracture
Ligament/Nerve/Tendon Damage
Penetration/Puncture
Scratch/abrasion
Separation of skin from tissue
Sickness/illness
Spinal injury
Sprain/Strain
Other
Unknown
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Additional Information
Describe what happened
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