Crew Services Group Incident Report Form

Today's date

Please select your Country(Required)

Australia

New Zealand

Your State(Required)

Crew Leader's Name(Required)

First Last

Date of incident(Required)

Time of incident(Required)

:

Customer & Location(Required)

Customer Location

Type of Incident

Injury

Near Miss

Hazard

Name of Injured person

First Last

Address of Injured person

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Injured Person's Contact Phone Number

Injured Person's Date of Birth

Employment Status

Casual (Crew Member/Crew Leader)

Permanent (State Manager/Assist. State Manager)

Contrator/Visitor

Customer

Description of the Injury

Location of the injury

Any contributing factors?

Is this a re-occurance of a previous injury?

Yes

No

Witness Name

First Last

Witness' Contact Phone Number

Was First Aid assistance provided?

Yes

No

Declined

If Yes, First Aider's Name

First Last

First Aid Certificate Expiry Date

Injury Treatment Outcomes - did the injured person...?

Return to Work/Shopping (if customer)

Seek medical assistance from a Private Doctor

Attend Hospital

Seek medical assistance from a Health Professional

Other - provide detail

Name of Private Doctor/Health Professional and Contact Phone Number

Safety Champion/Crew Leader Investigation

Contributing Factors

Impairment from Drugs/Alcohol

Lack of Understanding

Lighting

Misconduct

Work Practice

Safety Procedure

Work Area Layout

Other

Other - provide detail

What safety measures are already in place?

Was this avoidable and what are your recommendations for prevention?

Incident investigation photos

Accepted file types: jpg, jpeg, png, gif.

Incident investigation photos

Accepted file types: jpg, jpeg, png, gif.

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