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Incident Report Form

This Incident Reporting Form can be used to assist your workers report any work health or safety hazards or incidents. This form also assists businesses in keeping a record of such incidents and taking appropriate steps to address any existing or continued risk arising out of a reported hazard or incident.
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Document Overview

This form assists workers or witnesses in reporting the details of any hazards, incidents or injuries at the workplace in a timely manner, while ensuring that they are prompted for any relevant details. This form can also be used by management to record the results of any investigations into the matter, along with any outstanding action items, to assist with ensuring a safer workplace.

Use this Incident Reporting Form if:

  • You would like to have clear reporting processes in place for any possible safety risks or issues;
  • You need a way to record any previous hazards, incidents or injuries that may occur at your workplace;
  • You would like documentation to record the results of any internal investigations, or actions taken in connection with any previous safety risks or issues identified at your workplace; and
  • You want to implement a safer working environment where workers have the resources available to flag any safety issues.

What does this Form cover?

  • Details of any worker or witness reporting a safety issue;
  • Details of any reported hazard, incident or injury at the workplace, along with suggested solutions;
  • Results of any investigations by management into the hazard or incident;
  • Actions taken by management to address the hazard or incident;
  • Records of any notifications made to external parties, e.g. police, state safety regulator or the workers compensation insurer; and
  • Records of any workers compensation details in the event of an applicable injury.

Further Information:

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