Incident report form
Use this form to record any workplace incident properly: what happened, who was involved, injuries and treatment, whether the incident is NOTIFIABLE to your WHS regulator (a death, a serious injury or illness, or a dangerous incident), what was done immediately, and the corrective actions so it does not happen again.
Incident report form
Company: ____________
Site: ____________
Date: ____________
Incident details
| Date and time of incident: ____________ | N/A · Action | |
| Exact location on site: ____________ | N/A · Action | |
| Project / principal contractor: ____________ | N/A · Action | |
| Task being performed at the time: ____________ | N/A · Action | |
| Plant, equipment or substances involved: ____________ | N/A · Action |
People
| Injured or involved person(s), company and role: ____________ | N/A · Action | |
| Supervisor notified (name, time): ____________ | N/A · Action | |
| First aider who responded: ____________ | N/A · Action |
What happened
| Describe the sequence of events (attach page if needed) | N/A · Action | |
| What PPE was being worn | N/A · Action | |
| Site or weather conditions relevant to the incident | N/A · Action |
Injury and treatment
| Nature of injury and body part (if any) | N/A · Action | |
| First aid given on site | N/A · Action | |
| Taken to hospital / medical treatment required | N/A · Action | |
| Time lost or expected time off work | N/A · Action |
Is it NOTIFIABLE? (tick any that apply)
| A death | N/A · Action | |
| A serious injury or illness (e.g. fracture, amputation, serious burn, any injury needing immediate hospital treatment) | N/A · Action | |
| A dangerous incident (a near miss with the potential to seriously hurt someone: collapse, uncontrolled release of energy, fall of plant) | N/A · Action | |
| IF ANY TICKED: notify your WHS regulator IMMEDIATELY by the fastest means (usually phone), and PRESERVE the site until an inspector arrives or the regulator says otherwise, except to help an injured person or make the site safe | N/A · Action |
Notification record (if notifiable)
| Regulator notified (which, by whom, time, reference number): ____________ | N/A · Action | |
| Site preserved from (time): ____________ | N/A · Action | |
| Written record of the notification kept | N/A · Action |
Witnesses and evidence
| Witness names and contact details: ____________ | N/A · Action | |
| Photos taken of the scene | N/A · Action | |
| Statements collected | N/A · Action |
Causes and corrective actions
| Immediate cause: ____________ | N/A · Action | |
| Contributing factors (training, controls, conditions): ____________ | N/A · Action | |
| Corrective actions, owner and due date: ____________ | N/A · Action | |
| SWMS for the work reviewed before work resumed (required after an incident: reg 301 trigger) | N/A · Action |
Completed by: ____________________
Signature: ____________________
swmspack.com · Free printable checklist. Not legal advice; adapt to your site.
Common questions
▸Which incidents must be reported to the regulator?
Three things are notifiable under the WHS Act: a death, a serious injury or illness, and a dangerous incident (a near miss with the potential to seriously hurt someone). Notify your state regulator immediately by the fastest means and preserve the site.
▸How long do I keep incident records?
Keep the incident report with your site records. After a notifiable incident connected with high risk construction work, the SWMS for that work must be kept for at least two years.
▸Does an incident mean the SWMS was wrong?
It means something in the plan did not hold. An incident or near miss is a legal trigger to review the SWMS in consultation with the crew before that work resumes.
An incident is a mandatory trigger to review the SWMS before work resumes. Regenerate yours in minutes.
A checklist confirms controls are in place; a SWMS is the document the law requires before high risk construction work starts. Generate a site-specific one for your trade.