INCIDENT REPORT

INSTRUCTIONS

Employees are required to complete this form to report all work related incidents, injuries and illnesses– no matter how minor. This helps us to identify and correct hazards before they cause seriousinjuries.

THIS FORM SHALL BE COMPLETED BY THE SHOW CAPTAIN OR MANAGEMNET TOGETHER WITH THE INVOLVED STAFF MEMBER / MEMBERS

Personal Details

Full Name *

Phone number *

Date Of Birth *

Job Title *

Employee Status *

Full TimeCasual

Incident Details

Location of Incident *

Movie WorldSea World Factory 33Other

Date of incident *

Time of incident *

Name of witnesses (if any) *

Team captain / manager on duty *

If an injury was sustained major or minor the park nurse needs to be notified

This incident resulted in *

InjuryNo injuryProperty damageHazard identified

Has the nurse been notified *

YesNo (The nurse must be notified if any injury occurred, even minor)

What exactly happened *

Where exactly did the incident occur *

If an injury was sustained, what parts of the body were injured *

Has this part of the body been injured before (if yes please give details) *

If damage to property occurred what was was the damage (please attach photos) *

What could have been done to prevent this incident *

Add Pictures Here 1 (Optional)

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Add Picture Here 2 (Optional)

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Additional notes if required

Signature of employee *

Draw signature|Type signatureClear

Signature of team captain / manager *

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