HSW Report · VEC

HSW Report Form

HSW Event type

What type of HSW event are you reporting?

Reporter details

Reporter full name

Who completed this form?

Reporter contact number

Reporter email address

Reporter type

The reporter is a:

Provide employer contact details

Report date

When was this submitted?

Report review

Are you comfortable with this incident report going to the affected persons’ manager?

Incident details

Incident category

What are you reporting?

Incident date

When did this occur?

Incident address

Where did this occur? (address)

Incident location

Which site did this occur?

Incident location Other

Incident sublocation

Which room / area did this occur?

Incident sublocation Other

Incident description

Describe what happened in detail (who, what, when, where)

Actions undertaken

What actions have been taken to eliminate / reduce ongoing risk?

Incident reported to

What is the name / role of the VEC employee you reported this incident to?

Incident reported date

When was this first reported?

Hazard details

Hazard date and time

When was this identified?

Hazard location

Which site was this identified?

Hazard location other

Hazard address

Where was this identified? (address)

Hazard sublocation

Which room / area was this identified?

Hazard sublocation other

Hazard description

Describe the identified hazard (what, when, where etc)

Actions undertaken

What actions have been taken to eliminate / reduce ongoing risk?

Hazard reported to

What is the name/role of who this hazard was reported to? (e.g. direct manager, HSR etc) If you have not yet reported this to your direct manager or HSR, please ensure you do so.

Hazard reported date

When was this first reported?

Affected person details

Same as reporter details

Affected person name

Affected person contact number

Affected person email

Affected person type

The affected person is a:

Injury / illness description

Describe how this person has been affected (e.g. injury / illness)

Affected body part

Which body part has been affected?

Affected body part other

Treatment type

What type of treatment has been provided?

Treatment details

Provide further details on what treatment has been provided?

Work capacity

Has there been any impact on capacity to work safely?

Work capacity details

Describe any impact on capacity to work safely.

Witness details

Witness 1 – name and contact number

Witness 2 – name and contact number

Attachments

Attach a file