Incident Form

Name of the person reporting this incident: **

Contact number: **

Incident Report Number:

Position Title:

City:

Date of incident:

Time of incident:

Address:

Date first told you about the incident (if applicable):

Time first told you about the incident (if applicable):

Incident Type

Full Name:

Date Of Birth:

Address:

Involved/Witness

Injured ?

Medical Attention required?

Full Name:

Address:

Staff/Other

Involved/Witness

Injured ?

Medical Attention required?

(eg. What was client doing before incident) ?

Incident Description:

Immediate action taken by Staff:

Was any property or equipment damaged?

Police Contacted?

Details of Damage (if Applicable):

Incident reported to the Line Manager?

Manager's name:

Date:

Manager Name:

Contact:

Position:

Line Manager/ General manager Informed?

Informed Date:

Informed Time:

Report Quality checked

Does the severity of this incident require notification to Work Safe Victoria?

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