Incident Report Form
ANGLICAN ORGANISATION (School/Parish/Agency) ……………………………………………….……
PART A – TO BE COMPLETED BY PERSON INVOLVED OR FIRST CONTACT
Type of Incident
 Injury
 Near Miss
 Serious bodily injury
Notify WHSQ/ESO  No
 Work caused illness
 Dangerous event
 Yes Event I.D. _____________Was injury / illness fatal?  Yes
 No
Details of Injured person involved in incident
Given names
………………………………….. Surname
Date of Birth
…………………………………..  Male
……………………………………………..
 Female
Residential Address ……………………………………………………………………………………………...
Telephone:
Work …………………………….
Home ………………………………………………….
Worker (Paid & unpaid) …………………………………………………………………………………………
Occupation/Organisational position ……………………………………………………………………………...
 Full time
 Part Time
 Casual
 Volunteer
 Contractor
Non-Worker
Schools -  Student
Boarder Yes / No
Student No. ……….…………… House ……………….
Other  Member Public
Contractor’s / Employer’s Name and Address
………………………………………………………………………………………………………………………
Nature of Injury or Work Caused Illness, e.g. fracture, sprain and strain, burns, etc.
………………………………………………………………………………………………………………………
Bodily Location of Injury/illness: ..............................................................................................
Medical treatment
Treatment
 nil
 self
 first aid officer
 doctor only
 hospital
………………………………………………………………….……………………………………
Name of Person providing treatment ……………………….. Contact No. ………………………………...
 Admitted to hospital? Hospital name: …………………………………………………………………….....
Detail of Incident
Date:
/
/
Time:
Where did the event happen?
am / pm
………………………………………………………………………………
Reported to: ........................................................
Date Reported:
/
/
Describe what occurred:
Witnesses
Name/s & Contact No/s: .................................................... ....................................................................
Name(s) of Supervisor(s)/Leader(s)
………………………......... Ph.……………….....;
...................………………. Ph. ...............................
Person completing Part A:
Signature: ....…………………………….
Effective Date: 15/05/2013
Review Date: 15/05/2105
Version No: [Version No]
Name: ........………………………….
Page 1 of 2
Date: ………………….
Level: DSC . HRSS . . . .
Incident Report Form
PART B – DEPARTMENT HEAD / DELEGATE
INVESTIGATION
Describe how the incident happened (what started the sequence of events, the sequence of
events, the last thing that occurred). (Attach Additional Information sheet if necessary, including
statements from witnesses, photographs or sketches of the scene of the incident).
What factors do you believe contributed to the Incident?
1.
………………………………………………………………………………………………………………..
2.
………………………………………………………………………………………………………………..
3.
………………………………………………………………………………………………………………..
 Yes
Property damage
 No
Owner …………………..…………………………
Was a motor vehicle involved?  Yes
 No
Owner …………………………………..…………
Details/Description of damage ………………………………………………………………………………….
Injured person (if applicable)
Report Only 
Returned to work at …………am/pm
on ……/……/…… (Date). Has not returned to work
 Yes
WorkCover Claim lodged?
 No
 Yes
Parent / Guardian notified?

 No
Next of kin/contractor’s employer notified?
 Not applicable
 Yes
Workers involved were:
 No
Worker environment was:
Clean
 Yes
 No
Adequately lit
 Yes
 No
Well ventilated
 Yes
 No
A confined area
 Yes
 No
Other: ………………………………………………..
Uncluttered
 Yes
 No
………………………………………………………..
Other: ………………………………………………..
Qualified to undertake the work
 Yes  No
 Yes  No
Adequately supervised
Provided with documented safe work
 Yes  No
procedures
Action taken to prevent re-occurrence
1.
………………………………………………………………………………………………………………..
2.
………………………………………………………………………………………………………………..
3.
………………………………………………………………………………………………………………..
Action completed: Name: ..........................................Signature: …………………………Date:
/..../.....
Close Out
Manager: Name: .......................................... Signature: .................................. Date:
/
/
Have you received any claim from, or on behalf of the injured third party, either verbally or other
means?
Yes / No
If yes, please give details (attach more information)
.....................................................................................................................................................
Office Use Only
…………………………………..………
Safety Advisor (if applicable)
Effective Date: 15/05/2013
Review Date: 15/05/2105
Version No: [Version No]
………………………………….
Organisational Head (or delegate)
Page 2 of 2
Level: DSC . HRSS . . . .