Complete this form to report an incident or near hit at the workplace.

IMPORTANT NOTE: This is an initial post event notification tool only.

Always follow the site's emergency procedures:

- Seek medical assistance as required
- Notify your supervisor or nominated management representative immediately where a Category 1 Incident (see diagram below)

Please Enter the Global Construction Company Job Number or Site Address (required) *

Person Completing this Flash Report (required) *

Incident Details

Type (required) *

SafetyEnvironmental

Where environmental please choose from the following options:

What is the Severity Rating for this incident? (required) *

1234

If a Category 1, you must immediately contact your supervisor or nominated management representative.

Date the Incident Occurred

Time the Incident Occurred

Hours

Minutes

Where exactly at the job site did the incident occur?

Where a person was involved, what were they doing at the time of the incident?

Were there any witnesses to the incident? (required) *

YesNoUnsure

If yes, enter their names and contact numbers.

Attach photos of the incident if possible

No file chosen

Injured Persons Details

Full Name

Contact Number

Gender:

MaleFemale

Occupation

Nature of Injury:

Where "Unspecified/Other", please specify:

Bodily Location:

Where "Unspecified/Other", please specify:

Mechanism (The mechanism of injury/disease is the action, exposure or event which is the direct cause of the most serious injury or disease)

Where "Unspecified/Other", please specify:

Agency (The agency of injury / disease refers to the object, substance or circumstance directly involved in inflicting the injury or disease)

Where "Unspecified/Other", please specify:

Medical Treatment Provided

>> Multiple options can be selected.

None Required (Near Hit/Environmental)Will Monitor & Seek Treatment Later if RequiredOn-Site First AidMedical Rooms (GP/Clinic)Ambulance AttendanceHospital - Out PatientHospital - In Patient

Any Additional Comments:

Contributing Factors

What factors may have contributed to the incident?

Improvements

What improvements do you suggest might eliminate or reduce the likelihood of this happening again?

Your Name (required) *

Employer/Company (required) *

Signature (required) *

Other Involved Parties

Full Name

Employer/company/role

Signature

Full Name

Employer/company/role

Signature

Report An Incident