NDIS | Disability Service Providers | Enhanced Lifestyles

Incident - Near Miss - Hazard Report Form


CONFIDENTIAL

  • Sections 1 through to 6 to be fully completed when reporting an Incident
  • Sections 1 & 2 to complete for a Near Miss or Hazard Report
  • “Care Workers” refers to Lifestyles Attendants or Support Workers
  • Please return completed form to the office – whs@enhancedlifestyles.com.au

SECTION 1: My details

Person involved in incident or reporting a near miss or hazard

Incident number (WHS to complete): ________________

What was the location of the incident / near miss / hazard:

Location Title:

Address:

Postcode:

Section 2: (Tick one)

Date:

Date reported:

Incident time:

Who was the incident/Hazard reported to:

Incident / Near Miss description, including people involved

( Attach photos or supply drawings if required)

Section 3 My incident was caused by….

Other

Section 4 My injury was to....

Other

Section 5 My treatment required was…..

Other

Section 6 My lost time was...

I had Hours off from work

I had Days off from work

Report Incidents to Your Manager Immediately

Signing Section

Leave this empty:

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Signature Certificate
Document name: Incident - Near Miss - Hazard Report Form
lock iconUnique Document ID: 4a5aa20bc7b93520daf0efa28724c9d2714091af
Timestamp Audit
June 18, 2021 4:08 pm ACDTIncident - Near Miss - Hazard Report Form Uploaded by Enhanced Lifestyles - enhanced.website@gmail.com IP 125.168.64.82