Incident Report (Injury)

When to use this form: If any person is injured while at work

Report: Incident Report (Injury)

Your name

Name

Your phone number

Your Email

Who was injured, describe the injury, and how it happened?

Was First Aid provided?

Yes

Name & Number of person who provided First Aid

Did the injury result in attending a hospital?

Yes

Hospital Name

Time

Date

Location or site name

Address of incident

Street Address Suburb

Witness name

First Last

Witness phone number