/ F7-01 / Document Number: F7-01
Page 1 of 2 / Issue: 6
Hazard / Incident & Injury Report / Issue Date: 26thMarch2015
Approved by: Ian Powell / Review Date: 26thMarch 2017

5

Site: Corps/Centre / Division / Department
 / HAZARD /  / INCIDENT /  / INJURY

Section 1 (Details of injured Person)

Full Name / Date of Birth / Gender / Male / Female
Work Address / Home Address
Phone # / Mobile #
 / Officer /  / Employee /  / Volunteer /  / Contractor
 / Resident /  / Other (please specify);
Position / Supervisor / Contact details
Did worker complete shift? / YES / NO

Section 2 (Details of Hazard / Incident)

Date of Incident / / / / Time of Incident / a.m. / p.m. / Reported by
Reported to: / Date reported / / / / Time reported / a.m. / p.m.
Exact Location of Hazard or Incident:
Consider:
What is the hazard?
What was the incident?
What happened?
How did the incident occur?

Section 3 (Family member / Parent / Guardian contacted – Mandatory if person is under 18 years of age)

Name of person contacted / Relation to person
Contact Number / Date and time notified

Please attach extra documents, photos or certificates if necessary

Section 4(Details of Injury / incident if applicable)

Incident Type / Agency of Incident / Nature of Injury / Illness / Part of Body Effected / Area of Body
(identify on chart)
 Slip/Trip/Fall /  Manual Handling /  Sprain/Strain /  Head /
 Struck by/against /  Ergonomic /  Cuts/Abrasions /  Neck
 Psychological /  Work Method /  Laceration/Puncture /  Eye/Ear
 Caught in/between /  Work Environment /  Splinter/Foreign Body /  Face
 Lift/push/pull /  Motor Vehicle /  Concussion /  Back
Drug overdose /  Material/Substance / Swollen /  Chest/Stomach
 Twisting /  Bullying/Harassment /  Burn/Scald / Shoulder/Elbow/Arm
 Reaching /  Stress /  Mental /  Wrist/Hand/Fingers
 Vehicle Accident /  Trauma /  Multiple Injuries /  Leg/Knee/Ankle
 Chemical Exposure /  Hand tools /  Fracture/Dislocation /  Feet/Toes
 Heat/cold / Other Specify: /  Amputation /  Internal
 Repetition/overuse /  Dermatitis /  Other Specify:
 Electrical /  Infection
Other Specify: / Death
 Other Specify

Section 5 (Details of Treatment)

Treatment /  / First Aid /  / Doctor /  / Hospital
Name of First Aider:
Description of treatment given:
Name of Doctor/Hospital / Address:

Section 6 (Details of Witnesses)

Witness(s), (if applicable) / Name: / Name:
Phone: / Phone:

Section 7 (Details of person completing this form)

Name / Signature
Contact details

OFFICE USE ONLY (DHQ/THQ as required)

Reviewed by:
Name / Position / Copy returned to site/worker
(include date sent) / Yes / No
Forwarded to: /  / Workers Compensation team / Date / / /
 / THQ Insurance / Date / / /
Cost centre / Hazard rating ( if applicable)
Attachments /  / Medical certificate /  / Claim Form /  / Accounts /  / Other
Follow up Summary
Investigation or
Corrective action required

Keep Copy for Corps / Centre Records

This form and the Hazard / Incident & injury reporting procedure are available at: -whs.salvos.net

All printed documents are uncontrolled