Incident and Hazard Report Form
v2.1
Purpose. Workers use this form to report an injury, incident, near miss or hazard so it can be recorded in the incident and hazard register and investigated.
1.When to use this form
Complete this form for any injury, illness, near miss, property damage, aggressive customer event or hazard observed at work. It must be completed by the worker involved or their supervisor within 24 hours of the event and entered in the incident and hazard register.
2.Immediate actions
Before completing the form, make the area safe, provide or obtain first aid, and tell your supervisor. If the incident is notifiable, the manager on duty must contact WorkSafe Victoria immediately and the scene must not be disturbed.
3.Describing what happened
Describe the event in plain words, in the order it happened. Include the location, the task being performed, the equipment involved and the conditions. Do not speculate about blame.
4.Witnesses
Record the names and roles of anyone who saw the event. Witnesses can be asked to provide a short written statement.
5.Supervisor review
The supervisor must review the form, record the immediate corrective action taken, and assess whether a full investigation is required. The occupational health and safety coordinator will assign the investigation and track the corrective actions to closure.