Incident and Injury Report Form
1. General Information
Date of incident
Time of incident
Location of incident
Person reporting the incident
First Name
Last Name
Role/Position
Phone
2. Type of Incident (tick all that apply)
Type of Incident
Injury or illness
Property Damage
Safety Breach/Hazard
Security Incident
Disruptive Person/Behaviour
Child Safe Concern/Incident
Other (please specify):
3. People Involved
Name and role, injured or affected, phone number (for additional people please add to the back of the form)
4. Incident Description
Provide a detailed account of what happened, including events leading up to the incident
5. Immediate Action Taken
Immediate Action Taken
First aid administered
Person removed or isolated
Area secured
Authorities notified:
Police
Ambulance
SafeWork NSW
DCJ
Other action taken:
6. Details of injury/illness
Nature of injury (eg fracture, burn, sprain)
Body location (eg back, left forearm)
Treatment provided
Name of treating person
Is further treatment required?
Yes
No
Name of Dr or hospital
For Staff work related incidents only:
SafeWork NSW medical certificate received? (attach copies)
Yes
No
Injury Management requirement? (notify return to work coordinator)
Yes
No
Name of Return-to-Work Coordinator:
7. Details of Witnesses (if applicable attach written statements)
1. Witness Name
1. Witness phone contact
2. Witness name
2. Witness phone contact
8. Form completed by:
Name
Role
Date completed
Submit
