Incident Report Form

Name - Completing the Form *

First Name

Last Name

Report Type *

Injury: Damage or trauma caused by a person. Near miss: an incident in which no harm, damage or injury was obtained, but where they could have occurred given a slight change of circumstance. Incident: an incident in relation to a workplace that exposes a person to health or safety risks incident. Notifiable incident: A death or a person, a ‘Serious injury or illness’, or A ‘Dangerous incident’. Other: Anything else that isn’t covered by the above.

Hazard

Near Miss

Notifiable Incident

Injury

Incident

Other

Date *

MM

DD

YYYY

Time *

Hour

Minute

Second

AM PM

Site *

Hay Valley Farm

Angus Plains Farm

Name of Injured *

First Name

Last Name