Accident / Incident form
We need all the following information to make a report to hazardco
Email address *
Event Type *
Required
Reporting PCBU *
Your answer
PCBU responsible for involved worker
Your answer
Employee Name *
What happened (in short)? *
If it was a cut then which hand and size of the cut?
Your answer
Medical assistance required
Injury description and treatment received: *
Put out the fire; First-aid used; Burn kit used; give as much comprehensive details as possible.
Your answer
When it happened? *
MM
/
DD
/
YYYY
Time of incident/accident *
Time
:
(What)Why / How did it happen(in long)? *
all the details, contributing factors such as fatigue, weather, equipment failure, inattention, outsiders
Your answer
(Where)Job number *
Your answer
(Where)Job Address *
Your answer
Corrective action: *
what are you going to put in place to prevent a similar event happening
Your answer
Which other H2OFF staff were on that site? *
Your answer
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