Health and Safety Incident Report and Record
1 General
Report compiled by | Insert name |
Position of person compiling the report | Insert role |
Date of report | Insert |
2 Persons involved
Name of person(s) injured (or whose health and safety was compromised) | Insert name of person injured or whose health and safety was compromised |
Position or role of person(s) (where employed) | Insert details |
Status of person(s) (if not a person at work e.g., client/customer, visitor, etc.) | Insert details |
Gender of person(s) | Insert details |
Age of person(s) | Insert details |
Address of person(s) injured | Insert details |
Telephone number of person(s) injured | Insert details |
Name(s) of any witnesses to the incident | Insert details |
Address of any witnesses | Insert details |
Telephone number of any witnesses | Insert details |
Was the person affected a lone worker? | Insert details |
3 Incident location
Address of office or other location in which the incident happened | Insert address of office or other location in which the incident happened |