Fill and Sign the Osha Field Safety and Health Manual Mafiadoccom Form

HAZA RD A ND IN CID EN T R EPO RT F O RM In cid e nt N um berInjuries/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 HAZARDSurname: 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 spaceDate 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 DETAILSThis section to be completed only if an injury has occurredDescribe 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 spaceACCIDENT/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 representativeSignature: Signature: Signature: Print name: Print name: Print name: Date: / / Date: / / Date / / Head of academic/administrative unitRecommendations in D have been implemented: Yes No In Progress Signature: Print name: .Date / /