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Incident Report Form:
1. I am reporting a
*
Observation of Incident
Work-related Accident (Injury)
First Aid Incident
Close Call
2. Person reporting incident
*
First Name
Last Name
3a. Date of Incident
*
MM
DD
YYYY
3b. Time of Incident
*
Hour
Minute
Second
AM
PM
3c. Location of Incident
*
Buffet area
Restaurant area
Drive Through area
Bathroom
Kitchen
Storage Room
Drive Through Connecting Hallway
Rooftop
Backyard
External
4. Person involved in incident
*
First Name
Last Name
4a. Job Title
*
Front of House
Front of House + RSA
In Training
In Training + RSA
Supervisor
Manager
External
5. Were there any witnesses of the incident
*
Yes
No
Unsure
5a. If Yes, person who witnessed the incident
First Name
Last Name
5c. Witness Mobile
If the witness is a staff member, please disregard contact details.
(###)
###
####
6. What task was being performed at the time of the incident?
*
6a. What happened?
*
6b. What contributed to the incident occurring?
*
Noise
Lighting
Vibration
Damaged or unstable floor
Wet environments
Layout or design
Dust or fumes
Slip or trip hazard
Wrong equipment for the job
Inadequate maintenance
Inadequate guarding
Equipment failure
Material or equipment too heavy
Inadequate training provided
Other
6b continued.
6c. Did any factors of personal conduct contribute to the incident?
*
No
Procedure or policy not followed
No procedure exists
Fatigue
Change of routine
Lack of communication
Drugs or Alcohol
Time or production pressures
Distraction, personal issues or stress
Other
7. Was the incident avoidable?
*
Yes
No
7a. If yes, how?
8. Did the person involved require medical attention?
*
Yes
No
8a continued.
8b. How serious is the injury sustained
*
1 - Minor
2 - Moderate
3 - Severe
4 - Critical (Death)
9. Does the person involved require time off?
*
Yes
No
9a continued.
9b. Is this a notifiable incident?
*
Yes
No
9c. Does the person require ongoing assistance
*
No
Yes - Workcover claim
Yes - Time off work
Unsure
10. Has the issue within the workplace been reported to a manager?
*
Yes - incident aware
No - first notice
11. What are we going to do to fix the problem?
Checkbox
*
I declare that the incident being reported is genuine, and the information is valid or to the best of your ability.
Thank you!
