WHS FORM 10: INCIDENT AND INJURY REPORT

Details of injury (eg to a worker or visitor) and treatment

Date of Incident (required)

Time of Incident (am/pm) (required)

Nature of incident (required)
Near missFirst aidMedical treatment/doctor

Name of Injured Person (required)

Address (required)

Occupation (required)

Date of Birth (required)

Telephone (required)

Employer (required)

Activity in which the person was engaged at the time of injury (required)

Exact site location where injury occurred (required)

Nature of injury – eg fracture, burn, sprain, foreign body in eye (required)

Body location of injury (required)

Treatment given on site (required)

Name of treating person (required)

Referral for further treatment? (required)
YesNo

Name of Doctor or Hospital(if applicable)

Attach Copies of Referrals (if applicable)

Injury management requirement? (required)
YesNo

Notify return work coordinator

Name of return to work coordinator

Witness to incident (each witness may need to provide an account of what happened)

Witness name (required)

Witness contact (required)

Witness name

Witness contact

Details of incident (eg property, plant or environmental damage)

Date of Incident (required)

Time of Incident (am/pm) (required)

Location of incident (required)

Details of damage to equipment or property (required)

Name of person who received the report (required)

Telephone (required)

Description of incident (required)

Immediate response actions (eg barricades, isolation of power) to stabilise the situation (required)

Reported to

Reported to principal contractor? (required)
YesNo

Provide details (when, reported to and reported by):

Reported to authorities? (required)
YesNo

Provide details (when, reported to and reported by):

Reported to workers compensation insurer? (required)
YesNo

Provide details (when, reported to and reported by):

Completed by

Name (required)

Position (required)

Date (required)

Sign by typing name (required)