incidentinvreport – PHASafety

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Job No *

Site Address *

Supervisor Name *

Date / Time start of Investigation *

Date

Time

Person Completing Investigation *

If Supervisor, insert “as above”

Mobile Phone Number

Of the person completing Investigation

INCIDENT INVESTIGATION REPORT

Did Contractor/s complete a Risk Assessment? *

Yes
No
Not Applicable

Document Upload

Take a copy from the Job in Onsite Companion

Was the Contractor required to complete a SWMS *

Yes
No
Not Applicable

Document Upload

Take a copy from the Job in Onsite Companion

Incident Details

Date Incident occurred *

Approximate Time Incident occurred *

Classification of Incident *

First Aid only
Doctor/Medical Centre
Hospital (out patient)
Hospital (in patient)
Near Miss
Fatality
Incident report only
Other (fill below)

If Other state here *

Has the Incident been reported? *

Yes
No
Not a notifiable incident

List all that have been notified *

Including Emergency Services, Safe Work, QBCC (QLD only), construction manager etc.

Location on site incident occurred *

Describe with detail the location

Were there any witnesses? *

Yes
No

Name & Contact Details of Witness 1 *

Name & Contact Details of Witness 2

Name & Contact Details of Witness 3

Name & Contact Details of Witness 4

Name & Contact Details of Witness 5

Person/s Involved

Name Person 1 *

First

Last

Home Address *

Contact Phone Number *

Date of Birth

Job Title/Occupation *

Employer Details *

Contact details including Phone Number & Address

Add another person *

Yes
No

Name Person 2 *

First

Last

Home Address 2 *

Contact Phone Number 2 *

Date of Birth 2

Job Title/Occupation 2 *

Employer Details 2 *

Contact details including Phone Number & Address

Is this an incident report only? *

Yes
No

Detailed description of incident/near miss *

Anything that could cause harm or injury

Preventative action taken *

What has been done to prevent this from happening again

Was anyone Injured? *

Yes
No

NATURE OF INJURY / DAMAGE

Detail description of injury *

Must include what part of body injured

Detail any first aid or medical treatment administered (provide names) *

Make sure to obtain a report if available

Do you require additional information *

Yes
No

Additional information *

Reconstruct the sequence of events including contributing factors that led to the undesired event. *

Do you require additional information *

Yes
No

Additional information *

Corrective Action Taken (include description of action and person(s) responsible for actions.) *

Do you require additional information *

Yes
No

Additional information *

What is the probability of recurrence? *

Rare
Likely
Very Likely

File Upload

Take photos of Incident

File Upload

Take photos of Incident

File Upload

Take photos of Incident

File Upload

Take photos of Incident

Was there Property / Plant Damage? *

Yes
No

Describe damage *

Do you require additional information *

Yes
No

Additional information *

File Upload

Take photos of Incident

File Upload

Take photos of Incident

File Upload

Take photos of Incident

File Upload

Take photos of Incident

Was there a motor vehicle involved? *

Yes
No

File Upload

Take photos of Incident

File Upload

Take photos of Incident

File Upload

Take photos of Incident

File Upload

Take photos of Incident

Make & model *

e.g 2019 Ford Ranger

Vehicle Registration Number *

Details of damage or damage caused *

Do you require additional information *

Yes
No

Additional information *

Supervisor Signature

Clear Signature

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