Incident Report — Cleaning

HSEQ_FOR_06.5

Report an injury, near miss, hazard, property damage or other incident. Complete Part A and Part E for all incidents; complete Parts B–D only where they apply.

Don't fill this out:

Part A — Affected Person

Person Type

Full Name*

Date of Birth

Occupation

Employee number (if applicable)Four digits, given to you when onboarded (students end in SV) — find it on your payslip.

Department (if the affected person is an employee)

Phone number

Incident Details

Date/time of incident*

Location*

Date/time reported

Reported by

Reported to

Incident Type

Incident rating*

Pick the one that best fits. WHS can change it later.

Critical — Immediate threat to life, death, serious injury or assault, weapon violence, major fire, critical security failure.Cleaning examples: Death or injury needing an ambulance or hospital; chemical exposure needing emergency treatment; fire. High — Assault, fighting, credible threats, forced entry, significant theft/damage or security failure.Cleaning examples: Injury needing a doctor; chemical splash to eyes or skin; significant property damage; staff assaulted or threatened. Medium — Verbal abuse, nonviolent trespass, minor theft/damage, disruptive behaviour or contained security faults.Cleaning examples: First-aid-only injury; minor chemical exposure, no treatment; minor property damage; verbal abuse. Low — Minor breaches, resolved complaints, lost property or nuisance without continuing risk.Cleaning examples: Near miss; hazard found and fixed; resolved complaint; lost property.

Full details of incident*

What happened — or, for a near miss, what could have happened.

Task at time of incident

Action after incident

Witness

Was there a witness?

Yes No

Witness Name

Witness Phone number

Witness Statement

Part B — Injury (complete only if an injury occurred)

Location of injury

Lost time injury?

Yes No

No. of days

Worker's Compensation?

Yes No

Public Liability?

Yes No

Treatment Received

First Aid Doctor Police Ambulance

Attach medical report (if any)

Part C — External Party Injury (complete only if the injured person is a member of public, tenant, client, etc.)

Does the injured person take any medication?

Yes No

If Yes, details

Is the injured person pregnant?

Yes No

Was the person wearing glasses?

Yes No

Surface Conditions

Weather / Temperature

Lighting Conditions

Third Party (e.g. fight, cord, etc.)

If the incident involves a slip and/or fall:

Was food, drink or other substance found?

Yes No

Surveillance cameras?

Yes No

When was this area last cleaned?

How often is the area cleaned?

Part D — Property Damage (complete only for property damage)

Description of the damage

Cost of damage

Attach photos

Part E — Risk Control

Contributing Factors

Inadequate plant / equipment Inadequate procedure Inadequate management / supervision Inappropriate work environment Inadequate training Inappropriate actions / behaviour Lack of Attention Human Error Alcohol / drugs

Immediate actions

What control can be put in place to prevent this from happening again?

Who is to implement these controls / corrective actions?

Date by which action is to be taken

Part F — Acknowledgement

Typed full names are accepted as electronic signatures. Manager and HSE representative counter-sign on receipt.

Reported by (type full name)*

Date*

Manager name

HSE representative name

Send to

Select your site and manager. Sent to that manager and copied to the HSE representative / HR.