Title of Document Subject / Category

Incident Reporting Form Health and Safety

Document Owner

HEALTH AND SAFETY FLASH REPORT

Date & Time of incident: Who reported the incident:

Date & Time incident was reported: To whom was the incident reported:

Section: Incident Reference No:

Area / Department / Contractor:
A. INCIDENT INFORMATION

Incident Category (Mark with X): Safety X Health

Property Community Near Miss

Explosive Fire Damage/Vehic First Aid
Incident Incident
les
Incident Level of Risk Category Low X Moderate High Extreme
(Mark with X):
Description of the incident including task/s and actions just before incident occurred (What, Where, When, Who
and How): Illustration with photos.
On the 15…

Immediate actions taken:


Immediate Cause/s of the incident:

Recommended immediate actions taken to prevent a recurrence of the same incident:
Preventative action: Responsible Person Name: Target Date: Signature:

Has this incident, if required, already been reported to the required Authorities e.g. Dept. of Labour : YES NO

Signature…………................
Title of Document Subject / Category
Incident Reporting Form Health and Safety
Document Owner