Incident Report Form

Report a health and safety incident

Name *
Name
Type of incident: *
Details of injured person: *
Details of injured person:
Date of incident *
Date of incident
Time of incident *
Time of incident
Treatment *
Treatment provided by *
Treatment provided by
Name of witness to incident *
Name of witness to incident
Examples - bad lighting, obstructions, slippery surfaces, inappropriate behaviours or activities etc.