Incident and Hazard Report Form
v2.3
Purpose. This form is completed by the worker or supervisor for every injury, incident, near miss, hazard or environmental event, and supports the entry made in the WHS incident register.
1.When to use this form
Complete this form as soon as possible after the event and before the end of the shift. Use it for injuries, near misses, property damage, hazards that cannot be fixed on the spot, and spills. If you are unsure whether something needs reporting, report it.
2.How to complete it
Write what actually happened in plain words, in the order it happened. Record facts, not opinions about who was at fault. Include the plant, tools, materials and permits involved. Name any witnesses so the investigator can talk to them.
3.Immediate actions
Describe the first aid given, whether the plant was isolated, and what was done to make the area safe. Note the time the supervisor was told.
4.Supervisor section
The supervisor must review the report on the day, add the immediate controls put in place, assess whether the event is notifiable and forward the form to the Quality and Safety Manager. The supervisor must also enter the event in the WHS incident register.
5.Privacy
Personal and medical information on this form will be seen only by the supervisor, the Quality and Safety Manager, the return to work coordinator and the regulator where required. It must not be discussed at toolbox talks except in de-identified form.