Incident and Hazard Reporting Form

Physical and Psychosocial

In the event of any injury occurring at Let Minnow Cafe to either a team member or a customer the below form will act as an official reporting tool. Please be a precise as you can be and give as many details as possible.

Please complete the form below

Date of Incident or Hazard

YYYY

Time

Hour

Minute

Second

Name of person reporting incident/hazard

Date Reported

YYYY

Witnesses:

INJURED PARTY: Name

Activity in which the person was engaged at time of accident, near-miss or injury?

Nature of injury (includes physical and psychosocial)

If physical, part of the body injured?

TYPE OF INCIDENT OR HAZARD

DEFINITIONS: Hazard: a situation or thing that has the potential to harm a person, the environment or property Incident: an unplanned event resulting in, or having the potential for injury, ill health, damage or other loss. Injury: any physical or psychological damage caused by exposure to a hazard Near-miss: an incident that could have resulted in personal injury and / or damage to property Notifiable incident: an employer must notify SafeWork QLD of fatalities, serious injuries/illnesses (where the person is admitted to hospital) or dangerous incidents that occur at work as a result of conducting the business

Physical injury

First aid

Medical treatment

Psychological injury

Near-miss

Notifiable incident

Hazard

Property damage

INCIDENT DETAILS

Location of the incident or hazard:

Description of incident or hazard

What factors contributed to the incident or hazard?

Please be as precise as possible.