Hydraquip
incident report 02/05/2025 13:15:58

REPORT DETAILS

*Your name :
*Your department :
*Your role/title :
*Report type :
Near miss - No Injury Incurred
Minor - No Treatment
First Aid - Local Treatment
Medical Attention - Medical Treatment
Lost Time Incident - 1 Day + After Incident
*Where it happened :
*The date it happened :
*The time it happened :
:
No. of witnesses :
Witness names :

PERSON AFFECTED

*Full name :
*Role :
Dept :
DOB :
Nature of Injury :
No injury
Abrasion
Amputation
Bruise
Burn
Collision
Concussion
Cold Injury
Crushing/Crushed
Cut/Laceration
Death
Dermatitis
Dislocation
DSE Injury
Electric Shock
Fall-Slip-Trip
Foreign body
Fracture
Hearing
Heat Injury
Ingestion
Inhalation
Loss of Consciousness
Occupational Illness
Poison/Chemical
Puncture
Sprain/Strain

Other injury:
Area(s) affected : (please click on the text links or area on the body map)
Right ear
Right eye
Right shoulder
Right upper arm
Right elbow
Right forearm
Right wrist
Right hand
Right fingers
Right thumb
Right hip
Right upper leg
Right knee
Right lower leg
Right ankle
Right foot
Right toes
Right sole
None
Head top front
Head back
Face
Neck front
Neck back
Chest
Abdomen
Groin
Upper back
Middle back
Lower back
Buttocks
Left ear
Left eye
Left shoulder
Left upper arm
Left elbow
Left forearm
Left wrist
Left hand
Left fingers
Left thumb
Left hip
Left upper leg
Left knee
Left lower leg
Left ankle
Left foot
Left toes
Left sole
If the injury was to a different area please state :
*Action required :
*PPE correctly used? :
IF this person left the area : Destination :
Time departed :
:
Shift start time :
:
Shift end time :
:
No. of days lost due to this injury :
Affected person's address :

Affected person's phone number :

If member of public - Next of kin contact :

(You can upload photos after submitting this report)


INCIDENT DESCRIPTION

*Describe the incident (in detail, include specific location)

 

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