Section 1: Your Details
Section 2: About the Incident
Section 3: About the Injury (if applicable)
Section 4: About the Hazard/Cause
Section 5: Impact and Response
Section 6: Preventative Actions
Section 7: Confidentiality
(Optional—you may remain anonymous, but providing details may help us investigate more effectively)
Do you wish to remain anonymous?
YesNo
"Enter your full name."
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What type of event are you reporting?
—Please choose an option—InjuryIllnessNear Miss (no injury, but potential for harm)
Where did the incident occur? WorkplaceOfficeRemote WorkClient siteOther
When did the incident occur? Approximate time of the incident(s)
Who was involved?
SelfCo-workerContractorVisitorOther–specify
Were there any witnesses present?Were there any witnesses? YesNo
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What part of the body was affected?
What was the nature of the injury/illness? (e.g., cut, sprain, burn, strain, exposure, other)
Did you receive first aid?
Did you seek medical treatment?
What was the main cause of the incident? Unsafe conditionUnsafe actEquipment failureEnvironmentother–specify
Was any plant, equipment, or substance involved?
Were safe work procedures being followed at the time?
YesNoUnsure–explain
What immediate action was taken after the incident? First aidEvacuationEquipment shutdownReport to supervisorother
How has this incident affected your ability to perform your work? —Please choose an option—No impactMinor impactSignificant impactUnable to work—explain
What do you think could be done to prevent this incident (or similar) in the future?
Do you believe further action is required to make the workplace safe?
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Do you want to be contacted for follow-up?
How would you prefer to be contacted?
—Please choose an option—EmailPhoneOther
Do you require immediate support (e.g., medical review, counselling, workplace adjustment, leave)?
