Incident & Injury Form

Fill out this form if someone has been injured or involved in an incident while at work.

Must be filled out within 24 hours.

Incident and Injury Form

Name of injured person(Required)

First Last

Role of injured person(Required)

Department of injured

Date of identified hazard(Required)

Time of incident(Required)

Exact location of incident(Required)

What happened which resulted in injury?(Required)

Nature of injury- e.g. fracture, burn, sprain, foreign body in eye(Required)

Describe the body location of injury(Required)

Treatment given on site (if applicable)(Required)

Name of person treating (if applicable)(Required)

Who has been notified of the incident/injury(Required)

Team Leader

Room Leader

Manager

Authorities (ambulance/police)

Write name of the witness involved (if applicable)(Required)

Phone number of witness (if applicable)

This form has been completed by(Required)

First Last

Photo of incident/injury (if applicable)

Max. file size: 128 MB.

Signature(Required)