Incident Report Form

Date of Incident*

Time incident occurred*

Location:*

Type of Incident*

Property Damage

Motor Vehicle Accident

Theft

Near Miss

Describe what happened:*

Persons involved in the incident:*

Details of any witnesses:

Were Police or Ambulance required*

Yes

If so, provide police report number or hospital taken to:

Who or what caused the incident?*

Type of equipment or property involved:*

If a motor vehicle, what is the Registration Number?*

If damage occured on site, who is the Job Owner for the site?*

What is the extent of the damage?*

Upload photos if available

Drop files here or

Max. file size: 100 MB.

Were there any injuries as a result?*

Yes

Injury Report

Name of Injured Person	Type of Injury	What body part/s are affected?	What treatment was given?	Name of person/doctor providing initial treatment (if known):	Is this injury to be reported to Icare?	Is there lost time due to the injury?	If so, how many hours/days?	Actions

There are no Entries.

Estimated cost of repairs or replacement if known:

What precautions or steps have been put in place to eliminate/reduce the likelihood of this happening again?

Persons responsible for implementing and enforcing these measures:

Name	Signature	Actions

There are no Entries.

Does an Insurance claim need to be lodged?*

Yes

Does a Workers Compensation claim need to be lodged?*

Yes

Is a warning letter required?*

Yes

Name of person completing this report form:*

Full name

Signature*

Contact