Incident Report

For all staff — injuries, hazards, near misses & more

CONFIDENTIAL

Type of incident *

Tick all that apply.

Injury Property damage Workplace misconduct Hazard Near miss Other

Please specify

Please tick at least one incident type.

Your details

Name *

Please enter your name.

Job title *

Please enter your job title.

The incident

Date of incident *

Please enter the date.

Location *

Please enter the location.

Description * — what happened, in detail

Please describe the incident.

Witnesses — names and job titles

Injuries & treatment

Leave blank if no one was hurt.

Injuries — injuries you sustained

Medical treatment — first aid or treatment given

Did you go to hospital?

Hospital treatment — treatment received in hospital

Did you require stitches?

⚠︎

This report will be filed for WorkSafe. Because hospital treatment and stitches are both ticked, a copy of this report is placed in the WorkSafe folder as well as being sent to the person you choose below.

Response & follow-up

Immediate response — what was done straight after

Action taken — what has been done to resolve it

Supervisor notified — name and title

Send this report to *

Choose one person to receive your report.

RORyan O'ConnorDirector CSChristine ScholesStore Manager SHSam HortonManager

Please choose who should receive this report.

Declaration *

I declare that the details provided above are true and accurate to the best of my knowledge.

Signature — type your full name

Date

Please tick the declaration and sign with your full name.

Some required fields are missing — please check the items marked in red.

Report submitted

Submitted reports

Saved on this device (prototype). In the real app these are stored centrally.

Prototype
Reports are saved in this browser only — nothing is emailed yet.
Email delivery and the WorkSafe folder are simulated for review.