Incident Report Form Incident Type* SelectWork-related injuryWork-related illnessRoad traffic collisionNear-miss / Hazard alertFire incidentSecurity incidentEnvironmental incident Name of person reporting incident* Contact telephone number Email of person reporting incident Part of organisation* SelectConstructionManufacturingOffice Incident Details Date of the incident* Day 123456789101112131415161718192021222324252627828293031 / Month JanFebMarAprMayJunJulAugSeptOctNovDec / Year 20172018 Time of the incident* Select hour 010203040506070809101112131415161718192021222300 : Select minute 00153045 What happened?*Please provide as much detail as possible, including task and equipment being used. Please upload any photographic evidence. (optional)File type should be an image format of either gif, png, jpg or jpeg. Which site did the incident occur on?*Please give details of which site this incident occurred. Precisely where did the incident occur on the site?*Please record the exact location and characteristics on the site. Person Injured or Affected Were people injured or affected?* YesNo If "yes" then provide details below, if "no" then go to next section below. Category of person* SelectEmployeeAgency workerContractorSub-contractorMember of publicVisitor Name Description of Injury or AffectPlease provide as much detail as possible. Part of the Body Injured or Affected SelectHeadEyesBackArmHandBodyLeg/ankleFootGenitals Additional, more specific informationPlease be specific, for example: "middle finger on left hand". Details of any first aid or medical treatment givenPlease include what was given, when, and by whom? Did the Injured Person miss any work as a result of this incident?Please provide exact dates/time of any lost time. Phone number of Injured Person Email of Injured Person Witness Details Were there any witnesses to the incident?* YesNo If "yes" then provide details below, if "no" then go to next section below. Witness contact details Witness 1 Witness 2 Damage Was there any damage resulting from this incident?* YesNo If "yes" then provide details below. Damage details Damage classification SelectPropertyEnvironmentalEquipmentVehicle Description of damagePlease provide as much detail as possible. Thank you for completing this report, now press "Submit" below.
