Incident and Hazard Report Form
v2.2
Purpose. Used by any worker or supervisor to report an injury, near miss, hazard, property damage or environmental incident within 24 hours of the event.
1.When to use this form
Complete this form for every injury, illness, near miss, hazard, property damage, environmental incident, dangerous occurrence and stop work event. Report first, then complete the form. If you are not sure whether something needs reporting, report it.
2.How to complete it
Write what happened in plain words, in the order it happened, and include who was there. Describe the location precisely, for example the level, the grid line or the room. Do not guess at causes or blame a person. Attach photographs where they help.
3.What happens next
Give the completed form to your site supervisor, who will enter it in the WHS register and decide whether the WHS and Quality Manager must be called. You will be told the outcome of the investigation and any corrective action.
4.Serious incidents
If anyone has been seriously injured or a dangerous occurrence has happened, do not disturb the scene. The WHS and Quality Manager will decide whether WorkSafe Victoria must be notified.
5.Privacy
Personal and health information on this form is used only to manage the incident, the worker's recovery and any claim. It is stored securely by Business Support.