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Accident/Incident Report Form

Accident/Incident Report Form

This form is to be completed by the injured worker and submitted to V.I.P. Personnel as soon as practicable (e.g. within 24 hours).

This is a report for	Accident Incident Near Miss

PERSONAL DETAILS
Surname		First Name
Sex	Male Female	Date of birth
Address		Phone no
		E-Mail Address

CLIENT DETAILS
Client name *
Client address		Phone no
Supervisors name

DETAILS
Date Occurred		Time	am/pm
Date reported		Did you cease work?	Yes No
If yes, date & time ceased work		Time	am/pm
Have you returned to work?	Yes No
If yes, date & time returned to work		Time	am/pm
Name of witness
Did the accident/incident, near miss happen whilst
	A. Working at the usual place		Yes No
	B. Travelling to or from work		Yes No
	C. On an authorised break		Yes No
	D. Working elsewhere/other (If yes, please detail)		Yes No
What happened?

PLEASE FORWARD THIS FORM TO V.I.P.PERSONNEL AS SOON AS PRACTICABLE AFTER THE ACCIDENT/INCIDENT/NEAR MISS.
Where did it happen?
How did it happen?
What injury occurred (or could have occurred)?
How could it have been prevented?

		A. Change to induction	Yes No
		B. Change to training	Yes No
		C. Change to equipment	Yes No
		D. Change to work procedure	Yes No
		E. Change to work environment	Yes No
		F. Other (please provide details)	Yes No

Declaration:

This is to confirm I have read, completed and agree to the V.I.P. Incident/Accident/Form*	Yes
In order to declare the information you have provided is correct and to the best of your knowledge and you understand it is an offence to give false or misleading information, please tick the box above before you submit the form.

Security Code *

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