Quality Management Incident Report

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SECTION 1: My details Person involved in the incident or reporting a near miss or hazard Incident number (OHS to complete) EMPLOYEE or CONTRACTOR or VOLUNTEER Employee Directorate: (or Directorate responsible for contractor/volunteer) Infrastructure Sustainable Development Office of the CEO Community Business What is your worksite Location / Service / Facility : Name: Address: Postcode: Section 2: (Tick one) My Incident An injury occurred My Near Miss While performing a task but had no injury My Hazard Report Task or object that could cause an injury Date: Date reported: Incident time: Location incident occurred or hazard located: Who was the incident/Hazard reported to: Detailed description of Incident /

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