Health and Safety Incident Report

"*" indicates required fields

Please select an office/region:*

What are you reporting?*

When did it happen?*

Where did it happen?*

Other location selected, please provide details:*

Please describe the incident, including the events that lead up to it:*

What category best describes the incident?*

Witnesses:*

Please provide the names and contact details of anyone who witnessed the incident.

Who was involved?*

Please provide their name, role, and contact details.

What type of injury/illness/disease has been sustained?*

Please include which part/side of the body was affected.

What treatment was provided?*

Please include whether first aid and/or hospital treatment was needed.

Did the injured person go straight back to work afterwards?*

Please provide the duration of absence if known:*

Did you contact the office or on-call about this incident?*

Yes

Details of the person completing this form:*

Please include name/role/contact details.

Date form completed:*

Form completed by:*