Checklist · Site Safety & Administration
Incident and Near Miss Report
Records workplace incidents, injuries, and near misses in compliance with WHS Act notification and recording obligations.
35 checklist items · Last reviewed
Checklist Items
| Item | Pass / Yes | Fail / No |
|---|---|---|
| INCIDENT DETAILS | ||
| Report Date | ||
| Date of Incident | ||
| Time of Incident | ||
| Location of Incident | ||
| Site / Project Name | ||
| Incident Type (Injury / Near Miss / Property Damage / Environmental) | ||
| Was this a Notifiable Incident under WHS Act s35? | Yes | No |
| PCBU / Regulator Notified? | Yes | No |
| Notification Date / Time | ||
| PERSON(S) INVOLVED | ||
| Full Name of Injured/Involved Person | ||
| Employment Type (Employee / Contractor / Visitor) | ||
| Job Title / Trade | ||
| Length of Time in Role | ||
| INCIDENT DESCRIPTION | ||
| Describe what happened (sequence of events) | ||
| Task being performed at time of incident | ||
| Equipment / Machinery / Materials involved | ||
| Environmental conditions (weather, lighting, noise) | ||
| INJURY / DAMAGE DETAILS | ||
| Nature of Injury / Illness | ||
| Body Part(s) Affected | ||
| Medical Treatment Required | Yes | No |
| First Aid Administered? | Yes | No |
| First Aider Name | ||
| Referred to Hospital / Doctor? | Yes | No |
| Property or Equipment Damage Description | ||
| Estimated Damage Cost ($) | ||
| INVESTIGATION AND ROOT CAUSE | ||
| Immediate Cause(s) | ||
| Underlying / Root Cause(s) | ||
| Contributing Factors | ||
| Were existing controls adequate? | Yes | No |
| CORRECTIVE ACTIONS | ||
| Corrective Action(s) Required | ||
| Person Responsible | ||
| Target Completion Date | ||
| SIGN-OFF | ||
| Report Completed By | ||
| Supervisor / Manager Signature | ||
| WHS Representative Signature | ||