Report a Safety Issue

Date Of Incident

Time Of Incident

Host Employers Name

Location onsite where incident occurred

Surname

Other Names

Home Phone Number

Briefly outline the safety issue or how did the incident happen (include area and task, equipment, tools and people involved)

Name(s) of Witness(es)

Phone Witness(es)

Has Host Supervisor been advised? No Yes

Name of Hos Rep advised:

Date & Time advised:

Possible solutions / how to prevent recurrence – Do you have any suggestions for fixing the problem or preventing a recurrence?

Type of injury (e.g. burn, sprain, laceration)

Part(s) of the body affected: *

Was first aid treatment required: * No First Aid Medical Treatment