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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 VIP 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
Supervisors name
Phone no
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 VIP 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 VIP 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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