Incident / Near-miss report Person Involved: * First Name Last Name Other employee/s involved: Date of Report: * MM DD YYYY Date of Incident: * MM DD YYYY Time of incident: * Hour Minute Second AM PM Job site: * 2 Almeida Close, Torquay 5 Shapers Court, Jan Juc 12 Arthur Street, Hamlyn Heights 13 York Street. Geelong 64 McMillan Street, Anglesea 175 Oceania Drive, Curlewis Details of Injury / Near miss: * Check as appropriate: * Lost time Medical treatment First aid None of the above Details of Damage to Plant / Equipment / Property (if applicable): Description of incident: * Recommendations to Prevent Potential Future Incidents: Thank you for reporting your incident / near miss An official WorkSafe incident report will be filled out by HWI admin staff and sent to you to sign.
