Hazard / Incident Report Form | Hunter Wharf and Barge

Incident Category (Tick Appropriate Box)

person Witness patient)

Name of Person Involved

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Date / Time

Job Title

Supervisor

Date of Incident

Time of Incident

Task being performed at the time

Location Incident (site/office/vehicle etc): (copy)

Address of Incident:

Workers Comments

First person Informed of Incident

Witness Details (if any) (Name, Contact Number, Comments)

Witness Signature

Clear Signature

Environmental Incident Details

Area/Volume affected? (Land areas in square metres, water volume in cubic metres):

Environmental Impacts/Damage:

How Many People Where Exposed to the Incident? (List the number of workers and/or public exposed):

Step 3 – Incident / Investigation Details

How did the incident occur? (Include all details such as work conditions extent of damage, who has been notified)

List the injury, Incident or near miss in further detail (List any damage to property if applicable, in injury list all aspects to the injury)

Why did incident occur? (List all relevant factors which may have caused the incident)

How many people were exposed to the incident? (List the amount of workers or public exposed)

First Aid treatment given (List all first aid treatments given to patient)

Name of First Aid Attendant: *

First

Last

Signature of First Aid Attendant

Clear Signature

Corrective Actions

What corrective action will be taken

Name of person completing Report *

First

Last

Signature of person completing report

Clear Signature

Date