Member Form: Hazard or Incident Report

This form is for employees of FCHR Member Organisations to report an OHS hazard or incident. This report will be sent to a member of the Full Circle HR Team, who will connect with your employer and/or you directly depending on the circumstances. By submitting this form, you are giving us permission to discuss this matter with relevent parties and take appropriate action.

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Report a workplace Hazard, Near Miss or Accident

Hazard: Objects or situations that have the potential to cause harm to person, plant or the environment. Near Miss: An event has unintentionally occured, but there was no harm caused to person, plant or the environment. Accident: An event has unintentionally occured that results in damage, injury or harm to person, plant or the environment.

Your Name(Required)

First Last

Your Employer

Your Position/Job Title

Your Direct Line Manager

How Can We Reach You?

What's the best way for us to talk to you about your report?

Preferred Method of Contact

Phone

Incident/Hazard Information

What are you reporting?(Required)

Who was affected by this incident?(Required)

If this incident has affected another person(s) and you are making a report on their behalf, please provide the name, and contact information of the person(s) affected:

What was the date, day, time and location that the incident occured or the hazard was identified?(Required)

Please be clear and specific about the location details. Include information such as the ADDRESS, BUILDING and ROOM, along with a DESCRIPTOR such as "in the warehouse, centre of isle 3" or "in the breakroom, to the left under the window".

Description of the Incident or Hazard and resulting injury(Required)

Please provide clear and specific information about the incident or hazard, such as ACCIDENT: "fall from height off 2nd step of the ladder, they landed on their back on a hard surface, resulting in injury to back and suspected head injury " or HAZARD "trollies are regularly blocking the exit door to the left of the sales counter at the main entrance, preventing people from being able to leave via this exit during an emergency evacuation".

What treatment has occured?(Required)

Treatment Details

Please provide any details of treatment given, and by whom including any First Aid provided prior to additional medical treatment

Witnesses

Please provide the names and contact information for any witnesses to the incident, including first/last name and at least 1 contact point. Specify who was first on site if no witnesses.

Damage to Plant or Environment

Please provide details of any damage that was sustained to plant (property, equipment) and/or the environment as a result of the incident

Actions/Remedies

Please provide details of any actions that have already taken place to address the situation