Fill and Sign the Incident Report Form Template

H A Z A R D A N D I N C I D E N T R E P O R T F O R M Incident Number Injuries/illnesses: Sections A, B, C, D Environmental incidents, hazards, fires and property damage: Sections A, B, D SECTION A - DETAILS OF PERSON INVOLVED IN INCIDENT or PERSON REPORTING HAZARD Surname:       Given Name:       ID No:       Staff Contractor Visitor Other Department/Centre/Unit:       Division/Address:       Telephone:       SECTION B - INCIDENT DETAILS or NATURE OF HAZARD or DAMAGE Use separate sheet(s) if insufficient space Date of incident       /       / Time       . am/pm Date when symptoms first noticed or diagnosed: / / Location of incident: Room/space       Building:       Normal duties Travelling on duty In class/lecture Off-campus activity Playing sport Other       Brief description of incident, hazard, fire or damage (what happened?)                               SECTION C - INJURY/ILLNESS DETAILS This section to be completed only if an injury has occurred Describe injuries/illness including part(s) and side(s) of body affected:                   Name of witness or first person on scene:       Telephone:       Treatment details: None First aider On-site medical service Own doctor Hospital: in-patient casualty Signature of injured person: Date: / / Signature of person completing form: Date: / / If not injured person: Name:       ID No:       Please now give this form to your supervisor or your safety or environmental officer or health & safety representative Indicate if report is being forwarded directly to { insert name of company } without further details as confidential issues are involved SECTION D - INVESTIGATION AND PREVENTIVE ACTION Use separate sheet(s) if insufficient space ACCIDENT/INCIDENT: Notifiable Other Environmental Near miss Hazard Investigation results (why did it occur?)                               Preventive action recommended / taken:                               Attached : Correspondence Risk assessment Other       Supervisor (ID No. ) Safety/Environmental officer (Zone no. ) Health & safety representative Signature: Signature: Signature: Print name:       Print name:       Print name:       Date:       /       /       Date:       /       /       Date       /       /       Head of academic/administrative unit Recommendations in D have been implemented: Yes No In Progress Signature: Print name:       . Date       /       /