Site Safety & Administration
Incident and Near Miss Report
Records workplace incidents, injuries, and near misses in compliance with WHS Act notification and recording obligations.
35 checklist items
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Checklist Items
| Item | Pass / Yes | Fail / No |
|---|---|---|
| INCIDENT DETAILS | ||
| Report Date | ___________________________ | |
| Date of Incident | ___________________________ | |
| Time of Incident | ___________________________ | |
| Location of Incident | ___________________________ | |
| Site / Project Name | ___________________________ | |
| Incident Type (Injury / Near Miss / Property Damage / Environmental) | ___________________________ | |
| Was this a Notifiable Incident under WHS Act s35? | Yes ☐ | No ☐ |
| PCBU / Regulator Notified? | Yes ☐ | No ☐ |
| Notification Date / Time | ___________________________ | |
| PERSON(S) INVOLVED | ||
| Full Name of Injured/Involved Person | ___________________________ | |
| Employment Type (Employee / Contractor / Visitor) | ___________________________ | |
| Job Title / Trade | ___________________________ | |
| Length of Time in Role | ___________________________ | |
| INCIDENT DESCRIPTION | ||
| Describe what happened (sequence of events) | ___________________________ | |
| Task being performed at time of incident | ___________________________ | |
| Equipment / Machinery / Materials involved | ___________________________ | |
| Environmental conditions (weather, lighting, noise) | ___________________________ | |
| INJURY / DAMAGE DETAILS | ||
| Nature of Injury / Illness | ___________________________ | |
| Body Part(s) Affected | ___________________________ | |
| Medical Treatment Required | Yes ☐ | No ☐ |
| First Aid Administered? | Yes ☐ | No ☐ |
| First Aider Name | ___________________________ | |
| Referred to Hospital / Doctor? | Yes ☐ | No ☐ |
| Property or Equipment Damage Description | ___________________________ | |
| Estimated Damage Cost ($) | ___________________________ | |
| INVESTIGATION AND ROOT CAUSE | ||
| Immediate Cause(s) | ___________________________ | |
| Underlying / Root Cause(s) | ___________________________ | |
| Contributing Factors | ___________________________ | |
| Were existing controls adequate? | Yes ☐ | No ☐ |
| CORRECTIVE ACTIONS | ||
| Corrective Action(s) Required | ___________________________ | |
| Person Responsible | ___________________________ | |
| Target Completion Date | ___________________________ | |
| SIGN-OFF | ||
| Report Completed By | ___________________________ | |
| Supervisor / Manager Signature | ___________________________ | |
| WHS Representative Signature | ___________________________ | |