Incident and Hazard Report Form
v2.2
Purpose. Workers use this form to report injuries, near misses, hazards, chemical exposures, machinery incidents and property damage on the day they occur.
1.When to use this form
Complete this form for any injury to a person, any near miss, any hazard you cannot fix on the spot, any chemical spill or exposure, any machinery roll-over or collision, any livestock-related injury and any damage to vehicles, plant, fences or buildings. Complete it before the end of your shift and give it to your supervisor, who will enter it in the WHS Incident and Hazard Register.
2.Immediate actions first
Before completing the form, make the area safe, give or get first aid, isolate any machine involved and tell your supervisor. If a person needs medical attention, that comes first. For chemical exposure, decontaminate with water, keep the label and safety data sheet with the person and call for medical advice.
3.Describing what happened
Describe the sequence of events in plain words: the task, the equipment and controls in use, what happened, who was involved and the outcome. Record what you saw rather than what you think caused it. Name witnesses and attach photographs.
- Task being done and location
- Machine, chemical or animal involved
- What went wrong
- What was done immediately afterwards
4.Supervisor section
The supervisor records the initial risk rating, immediate corrective actions and whether investigation or regulator notification is required. The Business and Compliance Manager assigns an investigator for any incident rated medium or above.
5.Privacy
Information on this form is used to manage safety and meet legal obligations and is available only to the people managing the incident.