Vip Personnel Register Of Injury / Incident / Hazard & Investigation Form printable pdf download

Vip Personnel Register Of Injury / Incident / Hazard & Investigation Form

& Investigation Form

 Accident/Injury

 Incident

 Hazard

 Near Miss

PART A – INCIDENT DETAILS

Employee Name:

Workplace /Site:

Date of Birth:

Occupation:

Date of Incident: /

Time a.m./ p.m.

Date reported:

Time

a.m./ p.m.

Task being performed:

Location where accident occurred:

What happened? (e.g. slipped on wet floor whilst cleaning):

Witnesses:-

PART B - EMPLOYMENT DETAILS

Basis of Employment:  Permanent Employee  Casual Employee  Contractor  Visitor

How long at this job?

Years

Months

Average No. of hours/days per week (e.g. 12 hrs/4 days)

Shift:  Day  Afternoon  Night

Time shift started

a.m./ p.m.

PART C – CLIENT DETAILS

Client Name:

Client Address:

Phone Number:

Supervisors name:

Supervisors Phone Number:

Part D - INJURY DETAILS

Nature of injury (e.g. cut, bruising, sprain)

Body location of injury (e.g. shoulder, back)

 No treatment

 First Aid

Treatment Provided By:

Injury

Treatment

 Doctor

Details:-

 Hospital

Details:-

Is this a lost time injury?

Vip Personnel Register Of Injury / Incident / Hazard & Investigation Form

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