Incident Report Form

Part 1: Reporter Details

Part 2: Incident Details

DD slash MM slash YYYY
Time of incident:
:
DD slash MM slash YYYY
Time first told you about the incident (if applicable):
:
Incident Type

Part 3: Who was involved?

Participant Details
DD slash MM slash YYYY
Involved/Witness
Injured?
Medical Attention required?
Staff/Carer or Other details
Staff/Other
Involved/Witness
Injured?
Medical Attention required?

Part 4: Incident Background

Part 5: What happened?

Was any property or equipment damaged?
Police Contacted?
Incident reported to the Line Manager?
DD slash MM slash YYYY

Part 6: Manager’s report

Line Manager/ General manager Informed?
DD slash MM slash YYYY
Informed Time:
:
Report Quality checked:
Does the severity of this incident require notification to Work Safe Victoria?
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