HTML Preview Hazard Incident Report Form page number 1.
INCIDENT REPORT FORM
This form must be completed for an incident involving Injury/Illness, or reporting a workplace Hazard or Near Miss or involving Pr
operty/Environmental Damage
or an Unintentional GMO Release. Incidents involving actual or potential significant Injury/Illness must be reported immediately to the University’s Health,
Safety and Environment Team on Ph: 4921 8847.
PERSON COMPLETING THE FORM:
UoN Employee Student
Other (Please Specify:………………………………………………)
Employee or Student No.: ………………… First Name(s): …………………………………………….. Surname: ………………………………………..….……
Email: ……………………………………...……@newcastle.edu.au or ………………………………...……….@................................................................ (if not UoN)
Position/Job Title: ………………………………………………………………………………………………….…….. Contact Phone No.: …………………………………
INCIDENT TYPE:
What type of incident are you reporting
(Select one only?) Injury/Illness
Hazard
Near Miss
Was there any? Environmental Harm
Unintentional GMO Release
If you selected any of these options please provide a brief description of the Environmental Harm or GMO Release.
Environmental harm details:
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……………………………………………………………………………………………………………………………………………………………………………………………
Reported to FM via Maximo
Date: ……./……./……. Job/Work Order No.: ……………………………………
Unintentional GMO Release Details:
Details: (i.e. Name, No., Chief Investigator
Name & Release Details) ……
……………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………………………………………………………
INJU
RED/ILL PERSON DETAILS:
Family name of injured person: …………………………………………………….…….…. Given name(s): …………………………………..…………...…………..………
Staff No.: ………………..…Student No and Program of Study:…………………………………………………..……….DOB: …..../…..../…....
Gender: M F
Address (Home): ………………………………………………………………………..……………………………………………………………….. Postcode: ……………
Phone (Work): …………………………………….…..
(Home): ……………………..…..…………………….. (Mobile): ……………………..…...……………………..
INCIDENT/HAZARD/NEAR MISS DETAILS Date of Incident/Hazard/Near Miss: …../…./……….Time it Occurred: …….…AM/PM Date Reported: …./…./…….
Reported to: ………………………………………………………………..……
Location (Campus): ……………………………………………………….……………….
Building: ………………………………………………………….………. Room No.: ……………………...….. Grid Ref: (Attach Campus Map) …………………………
Specific Location (additional detail on location) …………………………………………………………………………………………………………………………………
DESCRIPTION OF INCIDENT/HAZARD/NEAR MISS.........................................................................................................................................................................
……………………………………………………………………………………………………………………………………………………………………………………………
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Work Location (e.g. Campus/Faculty/School/Division/Org. Unit/Offsite):
……………………………………………………………………………………………………….
Occupation/Activity: ……………………………………………………………………………………………………..……………………...….......................................
Employment Status: Permanent Fixed Term Casual Contractor Full-Time Part-time Student Visitor Other: ……………………..………
WITNESS DETAILS (If applicable(
Supervisor Name:
…………………………………………………………………………………………………....
Phone No: …………………………………………..
INJURY/ILLNESS DETAILS
Lost Time Date Stopped: ……./……./……. Time Stopped ……….AM/PM
Treatment Type (Select all applicable): First Aid
Hospital
Medical treatment at GP Clinic
Ambulance Called
Intend to Seek Medical Treatment
WorkCover Medical Certificate Issued
No Treatment Required
Description of Treatment Provided: …………………………………………………………………………………………………………………………………….……………
……………………………………………………………………………………………………………………………………………………………………………………………
Treatment Provided By: …………………………………………………………………………………….….… Phone No: …………………………………….…………
Description of Injury/Illness
(refer page 2): 1)Body location: 2)Nature: 3)Mechanism: 4)Agency:
……………………………………………………………………………………………………………………………………………………………………………………..……
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Task being undertaken at time of Injury/Illness: ………………………………………………………………………………………………………………….……………….
……………………………………………………………………………………………………………….......................................................................................................
Supervisor or Univer
sity Contact Person Details.
Name: ………………………………………………………………………….………………………….………… Phone No: …………………………………………………...
Address: …………………………………………………………………………………………………………………………………………………………………………………
Current Version: 2/12/2015
Page: 1 of 2
Property Damage