Accident / Incident form
We need all the following information to make a report to hazardco
Email address *
Event Type *
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? *
Time of incident/accident *
(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
Never submit passwords through Google Forms.
This form was created inside of H2OFF. Report Abuse - Terms of Service